hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number | TX,attester_name,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",,,,,,,,,,,,,,,
Hereford Regional Medical Center,4/1/2026,v3.0.0,"Deaf Smith County Hospital District, d.b.a. Hereford Regional Medical Center","540 W. 15th St, Hereford, TX 79045",1568454403,100121,"Stephen A. Kuehler, CEO",TRUE,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge | gross,standard_charge | discounted_cash,payer_name,plan_name,modifiers,standard_charge | negotiated_dollar,standard_charge | negotiated_percentage,standard_charge | negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge | min,standard_charge | max,standard_charge | methodology,additional_generic_notes
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,AETNA,NACO05,GP,6.23,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,339.63,339.63,AETNA,NACO05,GP,14.17,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Pt eval mod complex 30 min,97162,HCPCS,424,RC,outpatient,,,276.57,276.57,AETNA,NACO05,GP,19.07,,,74.8,19.07,74.85,1 through 10,19.07,74.85,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GP,8.57,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,AETNA,NACO05,GP,6.23,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GP,8.73,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,AETNA,NACO05,GP,6.38,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,430,RC,outpatient,,,103.23,103.23,AETNA,NACO05,GO,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GO,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,339.63,339.63,AETNA,NACO05,GO,14.17,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Ot eval low complex 30 min,97165,HCPCS,434,RC,outpatient,,,242.44,242.44,AETNA,NACO05,GO,19.56,,,19.56,19.56,19.56,1 through 10,19.56,19.56,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GO,8.57,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GP,8.57,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,AETNA,NACO05,GP,6.23,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Pt eval mod complex 30 min,97162,HCPCS,424,RC,outpatient,,,276.57,276.57,AETNA,NACO05,GP,19.07,,,74.8,19.07,74.85,1 through 10,19.07,74.85,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,AETNA,NACO05,GP,6.23,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GP,8.57,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,AETNA,NACO05,GP,6.23,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,AETNA,NACO05,GP,8.57,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,AETNA,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,AETNA,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,AETNA,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,AETNA,NACO05,,11.8,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
X-ray exam of knee 1 or 2,73560,HCPCS,320,RC,both,,,255.11,255.11,AETNA,NACO05,RT,255.11,,,215,215,215,1 through 10,215,215,percent of total billed charges,
Pharmacy - Extension of 025X - Self-administered drugs,637,HCPCS,637,RC,both,,,3,3,AETNA,NACO05,,3,,,,,,1 through 10,3,3,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,AETNA,NACO05,25,4.58,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of femur 2/>,73552,HCPCS,320,RC,both,,,264.93,264.93,AETNA,NACO05,RT,264.93,,,,,,1 through 10,264.93,264.93,percent of total billed charges,
X-ray exam of knee 1 or 2,73560,HCPCS,320,RC,both,,,255.11,255.11,AETNA,NACO05,LT,255.11,,,215,215,215,1 through 10,215,215,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,AETNA,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,16,16,AETNA,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,AETNA,NACO05,CG,21,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,AETNA,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,AETNA,NACO05,CG,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,17.6,17.6,AETNA,NACO05,,17.6,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Ccm/bhi by rhc/fqhc 20min mo,G0511,HCPCS,521,RC,outpatient,,,103,103,AETNA,NACO05,,10.93,,,10.93,10.93,10.93,1 through 10,10.93,10.93,percent of total billed charges,
Remove impacted ear wax uni,69209,HCPCS,521,RC,outpatient,,,135,135,AETNA,NACO05,,135,,,,,,1 through 10,135,135,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,16,16,AETNA,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,AETNA,NACO05,CG,25.2,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,AETNA,NACO05,CG,21,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,AETNA,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,AETNA,NACO05,CG,21,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,AETNA,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,AETNA,NACO05,CG,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,0.4,0.4,AETNA,NACO05,,0.4,,,0.1,0.1,14.41,40,0.1,16,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,AETNA,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,AETNA,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,AETNA,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,AETNA,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,AETNA,NACO05,,16,,,0.1,0.1,14.41,40,0.1,16,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,AETNA,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,AETNA,NACO05,CG,25.2,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,AETNA,NACO05,CG,18.11,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,AETNA,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Psytx w pt 60 minutes,90837,HCPCS,,,outpatient,,,347,347,Allied National Inc.,NACO05,,347,,,,,,1 through 10,347,347,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,AMBETTER,NACO05,,1564.24,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,AMBETTER,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,AMBETTER,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,AMBETTER,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,AMBETTER,NACO05,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,BLUE CROSS MEDICARE ADVANTAGE,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,BLUE CROSS MEDICARE ADVANTAGE,NACO05,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,BLUE CROSS MEDICARE ADVANTAGE,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Vitamin d 25 hydroxy,82306,HCPCS,301,RC,both,,,178.72,178.72,BLUE CROSS MEDICARE ADVANTAGE,NACO05,GA,178.72,,,,,,1 through 10,37.56,37.56,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,BLUE CROSS MEDICARE ADVANTAGE,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,BLUE CROSS MEDICARE ADVANTAGE,NACO05,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,167.89,167.89,BLUE CROSS MEDICARE ADVANTAGE,NACO05,,167.89,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Ct abd & pelvis w/contrast,74177,HCPCS,,,both,,,251,251,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,251,,,,,,1 through 10,251,251,percent of total billed charges,
Mri neck spine w/o dye,72141,HCPCS,,,both,,,203,203,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,203,,,,,,1 through 10,203,203,percent of total billed charges,
Ct chest spine w/o dye,72128,HCPCS,,,both,,,136,136,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,82.54,,,82.54,82.54,82.54,1 through 10,82.54,82.54,percent of total billed charges,
Ct head/brain w/o dye,70450,HCPCS,,,both,,,117,117,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,67.21,,,25.64,20.9,56.16,1 through 10,20.9,67.21,percent of total billed charges,
Ct neck spine w/o dye,72125,HCPCS,,,both,,,136,136,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,78.42,,,78.42,78.42,78.42,1 through 10,78.42,78.42,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,56.33,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,2.76,,,1.1,1.1,1.1,16,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,21.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,59,19.91,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,0.1,0.1,14.41,160,0.1,16,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,52.17,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,97.17,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.53,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,59,19.91,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,0.1,0.1,14.41,160,0.1,16,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,43,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,,,both,,,238,238,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,238,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,,,both,,,27,27,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,27,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
X-ray exam of ankle,73610,HCPCS,,,both,,,25,25,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,26,25,,,,,,1 through 10,25,25,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,,,outpatient,,,301.76,301.76,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,61.36,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Laboratory - Hematology,164.33,HCPCS,305,RC,both,,,164.33,164.33,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,20.17,,,20.17,20.17,20.17,1 through 10,20.17,20.17,percent of total billed charges,
Laboratory - Urology,22.13,HCPCS,307,RC,both,,,22.13,22.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,2.72,,,2.72,2.72,2.72,1 through 10,2.72,2.72,percent of total billed charges,
Pharmacy - Extension of 025X - Drugs requiring detailed coding,15,HCPCS,636,RC,both,,,15,15,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,1.84,,,1.84,1.84,1.84,1 through 10,1.84,1.84,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,11.77,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,41.33,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p new mod 45 min,99204,HCPCS,,,outpatient,,,288,288,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,84.3,,,84.3,84.3,84.3,1 through 10,84.3,84.3,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,0.1,0.1,14.41,160,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,51.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,84.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,67.74,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Prev visit est age 1-4,99392,HCPCS,,,outpatient,,,150,150,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,120.4,,,253.83,173.77,253.83,1 through 10,120.4,253.83,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Mmrv vaccine sc,90710,HCPCS,,,outpatient,,,458,458,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,338.33,,,338.33,338.33,338.33,1 through 10,338.33,338.33,percent of total billed charges,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,outpatient,,,75,75,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,45.78,,,45.78,45.78,45.78,1 through 10,45.78,45.78,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105.37,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,43,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,36.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,60.37,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,112.64,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,112.64,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,59,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Immune admin oral/nasal,90473,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,54,,,,,,1 through 10,54,54,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,140,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,1.62,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Subsequent prenatal care,0502F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,43,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Influenza assay w/optic,87804,HCPCS,,,both,,,32,32,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,32,,,,,,1 through 10,32,32,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,15.13,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,12.11,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,4.43,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,78.96,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,16,16,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,5.32,,,5.32,5.32,5.32,16,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.93,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,57.58,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,7.86,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,15.72,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Tdap vaccine 7 yrs/> im,90715,HCPCS,,,outpatient,,,94,94,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,57.03,,,57.03,57.03,57.03,1 through 10,57.03,57.03,percent of total billed charges,
4vhpv vaccine 3 dose im,90649,HCPCS,,,outpatient,,,385,385,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,159.4,,,159.4,159.4,159.4,1 through 10,159.4,159.4,percent of total billed charges,
Menacwyd/menacwycrm vacc im,90734,HCPCS,,,outpatient,,,271,271,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,174.04,,,174.04,174.04,174.04,1 through 10,174.04,174.04,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,26.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,BLUECROSS BLUESHIELD OF TEXAS,TXBS01,,49.67,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Unlisted special svc px/rprt,99199,HCPCS,,,outpatient,,,103,103,Cigna Supplemental Benefits,NACO05,,12.1,,,69.05,23.49,114.61,1 through 10,12.1,126,percent of total billed charges,
Unlisted special svc px/rprt,99199,HCPCS,,,outpatient,,,126,126,Cigna Supplemental Benefits,NACO05,,126,,,69.05,23.49,114.61,1 through 10,12.1,126,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,,,both,,,26,26,GOVERNMENT EMPLOYEES HEALTH AS,NACO05,26,26,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,,,outpatient,,,498.41,498.41,GOVERNMENT EMPLOYEES HEALTH AS,NACO05,,498.41,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,GREATWESTHEALTHCARE-CIGNA,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,GREATWESTHEALTHCARE-CIGNA,NACO05,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,43,43,GREATWESTHEALTHCARE-CIGNA,NACO05,QW,43,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,GREATWESTHEALTHCARE-CIGNA,NACO05,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Rbc sed rate nonautomated,85651,HCPCS,305,RC,both,,,29.43,29.43,GREATWESTHEALTHCARE-CIGNA,NACO05,,29.43,,,,,,1 through 10,5.41,5.41,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,GREATWESTHEALTHCARE-CIGNA,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,GREATWESTHEALTHCARE-CIGNA,NACO05,,139.68,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,GREATWESTHEALTHCARE-CIGNA,NACO05,,81.64,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,GREATWESTHEALTHCARE-CIGNA,NACO05,,158.81,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,GREATWESTHEALTHCARE-CIGNA,NACO05,,133.94,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,GREATWESTHEALTHCARE-CIGNA,NACO05,,18.81,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Vitamin d 25 hydroxy,82306,HCPCS,301,RC,both,,,178.72,178.72,GREATWESTHEALTHCARE-CIGNA,NACO05,,178.72,,,,,,1 through 10,37.56,37.56,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,GREATWESTHEALTHCARE-CIGNA,NACO05,,159.26,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Nuclear antigen antibody,86235,HCPCS,301,RC,both,,,57.56,57.56,GREATWESTHEALTHCARE-CIGNA,NACO05,90,57.56,,,,,,1 through 10,57.56,57.56,percent of total billed charges,
Vitamin b-12,82607,HCPCS,301,RC,both,,,73.67,73.67,GREATWESTHEALTHCARE-CIGNA,NACO05,,73.67,,,,,,1 through 10,73.67,73.67,percent of total billed charges,
Free assay (ft-3),84481,HCPCS,301,RC,both,,,88.3,88.3,GREATWESTHEALTHCARE-CIGNA,NACO05,,75.05,,,16.64,16.64,63.37,1 through 10,16.64,75.05,percent of total billed charges,
C-reactive protein,86140,HCPCS,302,RC,both,,,40.55,40.55,GREATWESTHEALTHCARE-CIGNA,NACO05,,40.55,,,,,,1 through 10,6.57,6.57,percent of total billed charges,
Prev visit est age 40-64,99396,HCPCS,,,outpatient,,,225,225,GREATWESTHEALTHCARE-CIGNA,NACO05,,171.82,,,160.41,151.28,169.54,1 through 10,149,171.82,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,GREATWESTHEALTHCARE-CIGNA,NACO05,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,GREATWESTHEALTHCARE-CIGNA,NACO05,,40.66,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,GREATWESTHEALTHCARE-CIGNA,NACO05,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,GREATWESTHEALTHCARE-CIGNA,NACO05,,187.36,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Vitamin b-12,82607,HCPCS,301,RC,both,,,73.67,73.67,GREATWESTHEALTHCARE-CIGNA,NACO05,,73.67,,,,,,1 through 10,73.67,73.67,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,GREATWESTHEALTHCARE-CIGNA,NACO05,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,GREATWESTHEALTHCARE-CIGNA,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Vitamin d 25 hydroxy,82306,HCPCS,301,RC,both,,,178.72,178.72,GREATWESTHEALTHCARE-CIGNA,NACO05,,178.72,,,,,,1 through 10,37.56,37.56,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,GREATWESTHEALTHCARE-CIGNA,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,GREATWESTHEALTHCARE-CIGNA,NACO05,,46.05,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Influenza dna amp probe,87502,HCPCS,306,RC,both,,,373.4,373.4,GREATWESTHEALTHCARE-CIGNA,NACO05,,373.4,,,,,,1 through 10,373.4,373.4,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,GREATWESTHEALTHCARE-CIGNA,NACO05,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,GREATWESTHEALTHCARE-CIGNA,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,HUMANA INC.,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,HUMANA INC.,NACO05,,50.28,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Ketone bodys qual,82009,HCPCS,301,RC,both,,,20.72,20.72,HUMANA INC.,NACO05,,20.72,,,,,,1 through 10,20.72,20.72,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,HUMANA INC.,NACO05,XU,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Drug test prsmv dir opt obs,80305,HCPCS,301,RC,both,,,101.7,101.7,HUMANA INC.,NACO05,59,101.7,,,,,,1 through 10,101.7,101.7,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,HUMANA INC.,NACO05,,154.71,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Assay of amylase,82150,HCPCS,301,RC,both,,,58.88,58.88,HUMANA INC.,NACO05,,58.88,,,30.39,30.39,30.39,1 through 10,30.39,30.39,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,HUMANA INC.,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,HUMANA INC.,NACO05,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,HUMANA INC.,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Rem mntr physiol param 16-30,99454,HCPCS,521,RC,outpatient,,,130,130,HUMANA INC.,NACO05,,47.43,,,47.43,47.43,47.43,1 through 10,47.43,47.43,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,38,38,HUMANA INC.,NACO05,QN,38,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,HUMANA INC.,NACO05,QN,1378.57,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,HUMANA INC.,NACO05,CG,225.37,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Admin pneumococcal vaccine,G0009,HCPCS,771,RC,outpatient,,,35,35,HUMANA INC.,NACO05,,33.02,,,33.02,33.02,33.02,1 through 10,33.02,33.02,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,636,RC,outpatient,,,373,373,HUMANA INC.,NACO05,,306.64,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,HUMANA INC.,NACO05,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Rem mntr physiol param 16-30,99454,HCPCS,521,RC,outpatient,,,130,130,HUMANA INC.,NACO05,,47.43,,,47.43,47.43,47.43,1 through 10,47.43,47.43,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,HUMANA INC.,NACO05,25,154.71,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,HUMANA INC.,NACO05,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,HUMANA INC.,NACO05,,50.28,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,HUMANA INC.,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Hydration iv infusion init,96360,HCPCS,450,RC,outpatient,,,771.33,771.33,HUMANA INC.,NACO05,,208.38,,,208.38,208.38,208.38,1 through 10,208.38,927.64,percent of total billed charges,
Normal saline solution infus,J7030,HCPCS,2376,DRG,both,,,50,50,HUMANA INC.,NACO05,,50,,,,,,1 through 10,50,100,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,HUMANA INC.,NACO05,,85.25,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,HUMANA INC.,NACO05,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,HUMANA INC.,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,HUMANA INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,HUMANA INC.,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,HUMANA INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,HUMANA INC.,NACO05,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay of blood lipoprotein,83721,HCPCS,301,RC,both,,,43.96,43.96,HUMANA INC.,NACO05,59,43.96,,,,,,1 through 10,43.96,43.96,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,HUMANA INC.,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Inj morphine pf epid ithc,J2274,HCPCS,5201,DRG,both,,,48.94,48.94,HUMANA INC.,NACO05,,48.94,,,,,,1 through 10,15,48.94,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,513.15,513.15,HUMANA INC.,NACO05,XU,208.38,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,HUMANA INC.,NACO05,XU,45.87,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
X-ray exam of femur 2/>,73552,HCPCS,320,RC,both,,,264.93,264.93,HUMANA INC.,NACO05,LT,264.93,,,,,,1 through 10,264.93,264.93,percent of total billed charges,
Insert temp bladder cath,51702,HCPCS,450,RC,outpatient,,,627.81,627.81,HUMANA INC.,NACO05,,627.81,,,,,,1 through 10,627.81,627.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,5503,DRG,both,,,15,15,HUMANA INC.,NACO05,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,HUMANA INC.,NACO05,25,296.07,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,HUMANA INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Hepatic function panel,80076,HCPCS,301,RC,both,,,92.1,92.1,HUMANA INC.,NACO05,,92.1,,,,,,1 through 10,92.1,92.1,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,HUMANA INC.,NACO05,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,44,44,HUMANA INC.,NACO05,QN,30.47,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,HUMANA INC.,NACO05,QN,316.89,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,HUMANA INC.,NACO05,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,HUMANA INC.,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ct thorax dx c-,71250,HCPCS,350,RC,both,,,1831.63,1831.63,HUMANA INC.,NACO05,,74.97,,,102.18,82.43,104.51,1 through 10,74.97,104.51,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,HUMANA INC.,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
X-ray exam of shoulder,73030,HCPCS,320,RC,both,,,262.74,262.74,HUMANA INC.,NACO05,LT,262.74,,,68.19,19.19,68.19,1 through 10,6.94,68.19,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,HUMANA INC.,NACO05,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,HUMANA INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,HUMANA INC.,NACO05,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,HUMANA INC.,NACO05,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,HUMANA INC.,NACO05,,1564.24,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of humerus,73060,HCPCS,320,RC,both,,,264.93,264.93,HUMANA INC.,NACO05,LT,264.93,,,,,,1 through 10,264.93,264.93,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,430,RC,outpatient,,,103.23,103.23,HUMANA INC.,NACO05,GO,103.23,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,226.42,226.42,HUMANA INC.,NACO05,GO,45.09,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,339.63,339.63,HUMANA INC.,NACO05,GO,46.05,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,226.42,226.42,HUMANA INC.,NACO05,GO,45.09,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,430,RC,outpatient,,,103.23,103.23,HUMANA INC.,NACO05,GO,103.23,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,339.63,339.63,HUMANA INC.,NACO05,GO,46.05,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Assay of creatinine,82565,HCPCS,301,RC,both,,,58.88,58.88,HUMANA INC.,NACO05,,58.88,,,,,,1 through 10,58.88,58.88,percent of total billed charges,
"Locm 300-399mg/ml iodine,1ml",Q9967,HCPCS,255,RC,both,,,32,32,HUMANA INC.,NACO05,,32,,,,,,100,32,32,percent of total billed charges,
Assay of urea nitrogen,84520,HCPCS,301,RC,both,,,20.85,20.85,HUMANA INC.,NACO05,,20.85,,,,,,1 through 10,20.85,20.85,percent of total billed charges,
Ct abd&plv wo cntr flwd cntr,74178,HCPCS,350,RC,both,,,2878.85,2878.85,HUMANA INC.,NACO05,,47.77,,,47.77,47.77,47.77,1 through 10,47.77,47.77,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,HUMANA INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,25.2,25.2,HUMANA INC.,NACO05,CG,25.2,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,100.8,100.8,HUMANA INC.,NACO05,CG,100.8,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,HUMANA INC.,NACO05,59,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,HUMANA INC.,NACO05,,40.66,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,HUMANA INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,HUMANA INC.,NACO05,,46.05,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Complete cbc automated,85027,HCPCS,305,RC,both,,,86.77,86.77,HUMANA INC.,NACO05,,86.77,,,6.65,6.65,6.65,1 through 10,6.65,6.65,percent of total billed charges,
Assay of magnesium,83735,HCPCS,301,RC,both,,,45.38,45.38,HUMANA INC.,NACO05,,45.38,,,,,,1 through 10,45.38,45.38,percent of total billed charges,
Renal function panel,80069,HCPCS,301,RC,both,,,103.61,103.61,HUMANA INC.,NACO05,,103.61,,,,,,1 through 10,103.61,103.61,percent of total billed charges,
Us exam pelvic complete,76856,HCPCS,,,both,,,95,95,HUMANA INC.,NACO05,26,31.19,,,29.61,28.34,30.87,1 through 10,28.02,31.19,percent of total billed charges,
Transvaginal us non-ob,76830,HCPCS,,,both,,,96,96,HUMANA INC.,NACO05,26,31.19,,,29.75,28.6,30.9,1 through 10,28.31,31.19,percent of total billed charges,
Prev visit est age 40-64,99396,HCPCS,,,outpatient,,,225,225,Insurance Management Services,NACO61,,149,,,160.41,151.28,169.54,1 through 10,149,171.82,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Insurance Management Services,NACO61,,90,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,984.35,984.35,Insurance Management Services,NACO06,,836.7,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,375.64,375.64,Insurance Management Services,NACO06,,319.29,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,1238.02,1238.02,Insurance Management Services,NACO06,,1052.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,1434.18,1434.18,Insurance Management Services,NACO06,,1219.05,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Radiology Diagnostic - General,320,RC,,,both,,,254.34,254.34,Insurance Management Services,NACO06,,216.19,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,591.8,591.8,Insurance Management Services,NACO06,,503.03,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,1057.05,1057.05,Insurance Management Services,NACO06,,898.49,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,1818.58,1818.58,Insurance Management Services,NACO06,,1313.92,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Prosthetic/orthotic devices,274,RC,,,outpatient,,,9,9,Insurance Management Services,NACO06,,6.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - Evaluation or reevaluation,424,RC,,,outpatient,,,276.57,276.57,Insurance Management Services,NACO06,,199.82,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,103.23,103.23,Insurance Management Services,NACO06,,74.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Magnetic Resonance Technology - General,610,RC,,,both,,,2384.4,2384.4,Insurance Management Services,NACO06,,529.76,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Freestanding Clinic - General,520,RC,,,outpatient,,,196,196,Insurance Management Services,NACO06,,166.6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,1842.79,1842.79,Insurance Management Services,NACO06,,1566.37,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
CT Scan - General,350,RC,,,both,,,1469.28,1469.28,Insurance Management Services,NACO06,,1469.28,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,4504.91,4504.91,Insurance Management Services,NACO06,,2550,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ambulance - General,540,RC,,,outpatient,,,1430.57,1430.57,Insurance Management Services,NACO06,,396.08,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,113.21,113.21,Insurance Management Services,NACO06,,113.21,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Magnetic Resonance Technology - General,610,RC,,,both,,,2384.4,2384.4,Insurance Management Services,NACO06,,529.76,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Freestanding Clinic - General,520,RC,,,outpatient,,,196,196,Insurance Management Services,NACO06,,166.6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,1842.79,1842.79,Insurance Management Services,NACO06,,1566.37,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
CT Scan - General,350,RC,,,both,,,1469.28,1469.28,Insurance Management Services,NACO06,,1469.28,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,4504.91,4504.91,Insurance Management Services,NACO06,,2550,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ambulance - General,540,RC,,,outpatient,,,1430.57,1430.57,Insurance Management Services,NACO06,,396.08,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,113.21,113.21,Insurance Management Services,NACO06,,113.21,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,103.23,103.23,Insurance Management Services,NACO06,,103.23,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.2,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,226.42,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,106.18,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,106.18,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
CT Scan - General,350,RC,,,both,,,1469.28,1469.28,Insurance Management Services,NACO06,,1469.28,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,4504.91,4504.91,Insurance Management Services,NACO06,,2550,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ambulance - General,540,RC,,,outpatient,,,1430.57,1430.57,Insurance Management Services,NACO06,,396.08,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,113.21,113.21,Insurance Management Services,NACO06,,113.21,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,103.23,103.23,Insurance Management Services,NACO06,,103.23,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.2,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,226.42,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,106.18,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,106.18,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,4448.16,4448.16,Insurance Management Services,NACO06,,2876.37,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
CT Scan - General,350,RC,,,both,,,1469.28,1469.28,Insurance Management Services,NACO06,,510,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ambulance - General,540,RC,,,outpatient,,,1426.57,1426.57,Insurance Management Services,NACO06,,1030.69,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,4448.16,4448.16,Insurance Management Services,NACO06,,2876.37,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
CT Scan - General,350,RC,,,both,,,1469.28,1469.28,Insurance Management Services,NACO06,,510,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ambulance - General,540,RC,,,outpatient,,,1426.57,1426.57,Insurance Management Services,NACO06,,1030.69,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,106.18,106.18,Insurance Management Services,NACO06,,76.71,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Physical Therapy - General,420,RC,,,outpatient,,,226.42,226.42,Insurance Management Services,NACO06,,163.59,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,4448.16,4448.16,Insurance Management Services,NACO06,,2876.37,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
CT Scan - General,350,RC,,,both,,,1469.28,1469.28,Insurance Management Services,NACO06,,510,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ambulance - General,540,RC,,,outpatient,,,1426.57,1426.57,Insurance Management Services,NACO06,,1030.69,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,MUTUAL OF OMAHA COMPANIES CLAI,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Sbsq nf care low mdm 20,99308,HCPCS,525,RC,outpatient,,,205,205,MUTUAL OF OMAHA COMPANIES CLAI,NACO05,CG,205,,,205,205,205,1 through 10,205,205,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,33.6,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Pt eval mod complex 30 min,97162,HCPCS,424,RC,outpatient,,,276.57,276.57,NOVITAS SOLUTIONS,TXMC61,GP,74.74,,,74.8,19.07,74.85,1 through 10,19.07,74.85,percent of total billed charges,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,636,RC,both,,,15,15,NOVITAS SOLUTIONS,TXMC61,JZ,15,,,,,,1 through 10,15,15,percent of total billed charges,
Anesthesia - General,370,RC,,,both,,,315,315,NOVITAS SOLUTIONS,TXMC61,,315,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,121,121,NOVITAS SOLUTIONS,TXMC61,,121,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Prothrombin time,85610,HCPCS,305,RC,both,,,42.02,42.02,NOVITAS SOLUTIONS,TXMC61,,42.02,,,,,,1 through 10,5.44,5.44,percent of total billed charges,
Cefazolin sodium injection,J0690,HCPCS,636,RC,both,,,30,30,NOVITAS SOLUTIONS,TXMC61,,30,,,,,,1 through 10,30,30,percent of total billed charges,
Recovery Room - General,710,RC,,,both,,,469.25,469.25,NOVITAS SOLUTIONS,TXMC61,,469.25,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,1256,1256,NOVITAS SOLUTIONS,TXMC61,,1256,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,30,30,NOVITAS SOLUTIONS,TXMC61,,30,,,5.32,5.32,5.32,1 through 10,5.32,6.39,percent of total billed charges,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,360,RC,outpatient,,,14270.41,14270.41,NOVITAS SOLUTIONS,TXMC61,,14270.41,,,,,,1 through 10,14270.41,14270.41,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,NOVITAS SOLUTIONS,TXMC61,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,376.99,376.99,NOVITAS SOLUTIONS,TXMC61,,376.99,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, propofol, 10 mg",J2704,HCPCS,636,RC,both,,,20.52,20.52,NOVITAS SOLUTIONS,TXMC61,,20.52,,,,,,1 through 10,20.52,20.52,percent of total billed charges,
"Inj, lidocaine in d5w, 1 mg",J2002,HCPCS,636,RC,both,,,15,15,NOVITAS SOLUTIONS,TXMC61,,15,,,,,,1 through 10,15,15,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,NOVITAS SOLUTIONS,TXMC61,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Normal saline solution infus,J7030,HCPCS,258,RC,both,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,,,,1 through 10,50,100,percent of total billed charges,
Fentanyl citrate injection,J3010,HCPCS,636,RC,both,,,15,15,NOVITAS SOLUTIONS,TXMC61,JZ,15,,,,,,1 through 10,15,15,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,170.24,170.24,NOVITAS SOLUTIONS,TXMC61,,170.24,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,NOVITAS SOLUTIONS,TXMC61,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,34.23,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Pt eval low complex 20 min,97161,HCPCS,424,RC,outpatient,,,248.1,248.1,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.85,74.85,74.85,1 through 10,74.85,74.85,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,9.15,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,7.61,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,167.89,167.89,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Pt eval mod complex 30 min,97162,HCPCS,424,RC,outpatient,,,276.57,276.57,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.8,19.07,74.85,1 through 10,19.07,74.85,percent of total billed charges,
X-ray exam of shoulder,73030,HCPCS,320,RC,both,,,262.74,262.74,NOVITAS SOLUTIONS,TXMC61,LT,68.19,,,68.19,19.19,68.19,1 through 10,6.94,68.19,percent of total billed charges,
Pt eval low complex 20 min,97161,HCPCS,424,RC,outpatient,,,248.1,248.1,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.85,74.85,74.85,1 through 10,74.85,74.85,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,58.85,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,34.23,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,69.24,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,58.85,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,69.24,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,9.15,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,NOVITAS SOLUTIONS,TXMC61,,2.2,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,NOVITAS SOLUTIONS,TXMC61,,5.08,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,7.61,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,NOVITAS SOLUTIONS,TXMC61,,5.66,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,NOVITAS SOLUTIONS,TXMC61,,5.66,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,9.15,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Pt eval mod complex 30 min,97162,HCPCS,424,RC,outpatient,,,276.57,276.57,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.8,19.07,74.85,1 through 10,19.07,74.85,percent of total billed charges,
X-ray exam of shoulder,73030,HCPCS,320,RC,both,,,262.74,262.74,NOVITAS SOLUTIONS,TXMC61,LT,68.19,,,68.19,19.19,68.19,1 through 10,6.94,68.19,percent of total billed charges,
Pt eval low complex 20 min,97161,HCPCS,424,RC,outpatient,,,248.1,248.1,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.85,74.85,74.85,1 through 10,74.85,74.85,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,58.85,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,34.23,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,69.24,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,58.85,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,NOVITAS SOLUTIONS,TXMC61,GP,69.24,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,NOVITAS SOLUTIONS,TXMC61,,2.2,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,25,25,NOVITAS SOLUTIONS,TXMC61,,18.31,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,7.61,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,25,25,NOVITAS SOLUTIONS,TXMC61,,18.31,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,59,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,9.15,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,NOVITAS SOLUTIONS,TXMC61,59,3.11,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Sc std microdil/agar dil,87186,HCPCS,306,RC,both,,,66.07,66.07,NOVITAS SOLUTIONS,TXMC61,,8.48,,,8.48,8.48,8.48,1 through 10,8.48,8.48,percent of total billed charges,
Urine culture/colony count,87086,HCPCS,306,RC,both,,,69.62,69.62,NOVITAS SOLUTIONS,TXMC61,,7.91,,,16.23,9.57,32,1 through 10,7.91,35.94,percent of total billed charges,
Culture aerobic identify,87077,HCPCS,306,RC,both,,,37.36,37.36,NOVITAS SOLUTIONS,TXMC61,,7.92,,,7.92,7.92,7.92,1 through 10,7.92,7.92,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,21.26,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,29.1,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,34.23,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Pt eval mod complex 30 min,97162,HCPCS,424,RC,outpatient,,,276.57,276.57,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.8,19.07,74.85,1 through 10,19.07,74.85,percent of total billed charges,
Pt eval low complex 20 min,97161,HCPCS,424,RC,outpatient,,,248.1,248.1,NOVITAS SOLUTIONS,TXMC61,GP,74.85,,,74.85,74.85,74.85,1 through 10,74.85,74.85,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,34.23,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,NOVITAS SOLUTIONS,TXMC61,,5.66,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,NOVITAS SOLUTIONS,TXMC61,,2.2,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,7.61,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,NOVITAS SOLUTIONS,TXMC61,,5.08,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Basic metabolic pnl total ca,80048,HCPCS,301,RC,both,,,99.29,99.29,NOVITAS SOLUTIONS,TXMC61,,8.29,,,8.29,8.29,8.29,1 through 10,8.29,8.29,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,GA,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,9.15,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,NOVITAS SOLUTIONS,TXMC61,,68.19,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,430,RC,outpatient,,,339.63,339.63,NOVITAS SOLUTIONS,TXMC61,GO,56.44,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Bls,A0428,HCPCS,540,RC,outpatient,,,916.33,916.33,NOVITAS SOLUTIONS,TXMC61,QN,271.66,,,271.66,271.66,271.66,1 through 10,271.66,271.66,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,24,24,NOVITAS SOLUTIONS,TXMC61,QN,13.3,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,167.89,167.89,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,7.61,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,350,RC,both,,,1875.89,1875.89,NOVITAS SOLUTIONS,TXMC61,LT,137.46,,,102.2,73.98,130.41,1 through 10,66.93,137.46,percent of total billed charges,
Assay of blood/uric acid,84550,HCPCS,301,RC,both,,,43.58,43.58,NOVITAS SOLUTIONS,TXMC61,,43.58,,,,,,1 through 10,43.58,43.58,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,33.86,33.86,NOVITAS SOLUTIONS,TXMC61,,33.86,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,NOVITAS SOLUTIONS,TXMC61,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,NOVITAS SOLUTIONS,TXMC61,,166.69,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
"Locm 300-399mg/ml iodine,1ml",Q9967,HCPCS,255,RC,both,,,32,32,NOVITAS SOLUTIONS,TXMC61,,32,,,,,,100,32,32,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Pharmacy - Drugs incident to radiology,255,RC,,,both,,,7.9,7.9,NOVITAS SOLUTIONS,TXMC61,,7.9,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,NOVITAS SOLUTIONS,TXMC61,,36.7,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,NOVITAS SOLUTIONS,TXMC61,25,327.02,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Ko elastic w/joints pre ots,L1812,HCPCS,274,RC,outpatient,,,44,44,NOVITAS SOLUTIONS,TXMC61,,34.5,,,34.5,34.5,34.5,1 through 10,34.5,34.5,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,NOVITAS SOLUTIONS,TXMC61,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
X-ray exam hips bi 2 views,73521,HCPCS,320,RC,both,,,288.61,288.61,NOVITAS SOLUTIONS,TXMC61,,288.61,,,10.79,10.79,10.79,1 through 10,10.79,10.79,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,968,968,NOVITAS SOLUTIONS,TXMC61,QN,420.22,,,30.47,16.73,342.27,48,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,NOVITAS SOLUTIONS,TXMC61,QN,516.16,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,24.42,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,339.63,339.63,NOVITAS SOLUTIONS,TXMC61,GP,55.56,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,24.42,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,24.42,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,24.42,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,38.75,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,24.42,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,NOVITAS SOLUTIONS,TXMC61,GP,24.42,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,33.6,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,33.6,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,33.6,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,33.6,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,339.63,339.63,NOVITAS SOLUTIONS,TXMC61,GP,55.56,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,NOVITAS SOLUTIONS,TXMC61,GP,15.93,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,NOVITAS SOLUTIONS,TXMC61,GP,33.6,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,187.36,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Basic metabolic pnl total ca,80048,HCPCS,301,RC,both,,,99.29,99.29,NOVITAS SOLUTIONS,TXMC61,,99.29,,,8.29,8.29,8.29,1 through 10,8.29,8.29,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,187.36,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,NOVITAS SOLUTIONS,TXMC61,,5.66,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,NOVITAS SOLUTIONS,TXMC61,,5.08,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,NOVITAS SOLUTIONS,TXMC61,,9.15,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,NOVITAS SOLUTIONS,TXMC61,,2.2,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,NOVITAS SOLUTIONS,TXMC61,,7.61,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,NOVITAS SOLUTIONS,TXMC61,,9.52,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,NOVITAS SOLUTIONS,TXMC61,,5.08,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,NOVITAS SOLUTIONS,TXMC61,,38.47,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,NOVITAS SOLUTIONS,TXMC61,,13.12,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,NOVITAS SOLUTIONS,TXMC61,,16.46,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,NOVITAS SOLUTIONS,TXMC61,,10.35,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,92.11,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,92.11,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,92.11,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,92.11,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transj care mgmt high f2f 7d,99496,HCPCS,521,RC,outpatient,,,449,449,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,174.43,174.43,174.43,1 through 10,174.43,174.43,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,75.65,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,NOVITAS SOLUTIONS,TXMC61,,47.42,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,54,54,NOVITAS SOLUTIONS,TXMC61,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,80,80,NOVITAS SOLUTIONS,TXMC61,,80,,,0.1,0.1,14.41,80,0.1,16,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,NOVITAS SOLUTIONS,TXMC61,CG,218.04,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,NOVITAS SOLUTIONS,TXMC61,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,NOVITAS SOLUTIONS,TXMC61,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,521,RC,outpatient,,,108,108,NOVITAS SOLUTIONS,TXMC61,59,348.86,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,636,RC,both,,,16,16,NOVITAS SOLUTIONS,TXMC61,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,NOVITAS SOLUTIONS,TXMC61,CG,174.43,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,,,outpatient,,,301.76,301.76,NOVITAS SOLUTIONS INC.,TXMC01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,,,both,,,26,26,NOVITAS SOLUTIONS INC.,TXMC01,26,26,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,,,outpatient,,,498.41,498.41,NOVITAS SOLUTIONS INC.,TXMC01,,498.41,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Sbsq hosp ip/obs moderate 35,99232,HCPCS,,,both,,,224,224,NOVITAS SOLUTIONS INC.,TXMC01,,58.74,,,36.31,18.37,54.25,1 through 10,13.88,58.74,percent of total billed charges,
Sbsq hosp ip/obs moderate 35,99232,HCPCS,,,both,,,224,224,NOVITAS SOLUTIONS INC.,TXMC01,,224,,,36.31,18.37,54.25,1 through 10,13.88,58.74,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,,,outpatient,,,498.41,498.41,NOVITAS SOLUTIONS INC.,TXMC01,,77.53,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,,,both,,,238,238,NOVITAS SOLUTIONS INC.,TXMC01,26,62.2,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,,,both,,,26,26,NOVITAS SOLUTIONS INC.,TXMC01,26,6.52,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Insert non-tunnel cv cath,36556,HCPCS,,,both,,,1200,1200,NOVITAS SOLUTIONS INC.,TXMC01,,50.71,,,50.71,50.71,50.71,1 through 10,50.71,50.71,percent of total billed charges,
Emergency dept visit hi mdm,99285,HCPCS,,,outpatient,,,732.8,732.8,NOVITAS SOLUTIONS INC.,TXMC01,25,112.41,,,112.41,112.41,112.41,1 through 10,112.41,2348.25,percent of total billed charges,
Ct head/brain w/o dye,70450,HCPCS,,,both,,,117,117,NOVITAS SOLUTIONS INC.,TXMC01,26,30.37,,,25.64,20.9,56.16,1 through 10,20.9,67.21,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,,,outpatient,,,498.41,498.41,NOVITAS SOLUTIONS INC.,TXMC01,,46.2,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,both,,,259,259,NOVITAS SOLUTIONS INC.,TXMC01,26,66.93,,,102.2,73.98,130.41,1 through 10,66.93,137.46,percent of total billed charges,
X-ray exam of shoulder,73030,HCPCS,,,both,,,27,27,NOVITAS SOLUTIONS INC.,TXMC01,26,6.94,,,68.19,19.19,68.19,1 through 10,6.94,68.19,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,OMAHA SUPPLEMENTAL INSURANCE C,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,,,outpatient,,,301.76,301.76,OMAHA SUPPLEMENTAL INSURANCE C,NACO05,,0.78,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Sbsq hosp ip/obs moderate 35,99232,HCPCS,,,both,,,224,224,OMAHA SUPPLEMENTAL INSURANCE C,NACO05,,13.88,,,36.31,18.37,54.25,1 through 10,13.88,58.74,percent of total billed charges,
1st hosp ip/obs moderate 55,99222,HCPCS,,,both,,,408,408,OMAHA SUPPLEMENTAL INSURANCE C,NACO05,,23,,,23,23,23,1 through 10,23,23,percent of total billed charges,
Rmvl skin tags up to&inc 15,11200,HCPCS,521,RC,outpatient,,,154,154,OMAHA SUPPLEMENTAL INSURANCE C,NACO05,,154,,,,,,1 through 10,154,154,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,OMAHA SUPPLEMENTAL INSURANCE C,NACO05,CG,25.2,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,both,,,32,32,Prominence Health Plan,NACO05,26,10.47,,,10.47,10.47,10.47,1 through 10,10.47,10.47,percent of total billed charges,
X-ray exam hips bi 2 views,73521,HCPCS,,,both,,,32,32,Prominence Health Plan,NACO05,26,10.79,,,10.79,10.79,10.79,1 through 10,10.79,10.79,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,,,both,,,46.05,46.05,Prominence Health Plan,NACO05,,5.95,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Psa screening,G0103,HCPCS,,,outpatient,,,122.65,122.65,Prominence Health Plan,NACO05,,18.91,,,18.91,18.91,18.91,1 through 10,18.91,18.91,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,,,both,,,157.58,157.58,Prominence Health Plan,NACO05,,17.29,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Prominence Health Plan,NACO05,,9.61,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,,,both,,,164.33,164.33,Prominence Health Plan,NACO05,,8,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,,,both,,,40.66,40.66,Prominence Health Plan,NACO05,,5.33,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,,,both,,,96.05,96.05,Prominence Health Plan,NACO05,,10,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Lipid panel,80061,HCPCS,,,both,,,187.36,187.36,Prominence Health Plan,NACO05,,13.04,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Free assay (ft-3),84481,HCPCS,,,both,,,88.3,88.3,Prominence Health Plan,NACO05,,16.64,,,16.64,16.64,63.37,1 through 10,16.64,75.05,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,,,both,,,33.16,33.16,Prominence Health Plan,NACO05,,3.26,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,,,both,,,186.84,186.84,Prominence Health Plan,NACO05,,10.87,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
X-ray exam hips bi 2 views,73521,HCPCS,,,both,,,288.61,288.61,Prominence Health Plan,NACO05,,288.61,,,10.79,10.79,10.79,1 through 10,10.79,10.79,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,,,both,,,164.33,164.33,Prominence Health Plan,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,,,both,,,186.84,186.84,Prominence Health Plan,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,both,,,379.06,379.06,Prominence Health Plan,NACO05,,379.06,,,10.47,10.47,10.47,1 through 10,10.47,10.47,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,22.13,22.13,Prominence Health Plan,NACO05,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,,,both,,,96.05,96.05,Prominence Health Plan,NACO05,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
C-reactive protein,86140,HCPCS,,,both,,,40.55,40.55,Prominence Health Plan,NACO05,,40.55,,,,,,1 through 10,6.57,6.57,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Prominence Health Plan,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Lipid panel,80061,HCPCS,,,both,,,187.36,187.36,Prominence Health Plan,NACO05,,13.04,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Rbc sed rate nonautomated,85651,HCPCS,,,both,,,29.43,29.43,Prominence Health Plan,NACO05,,29.43,,,,,,1 through 10,5.41,5.41,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,,,both,,,40.66,40.66,Prominence Health Plan,NACO05,,5.33,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,,,both,,,186.84,186.84,Prominence Health Plan,NACO05,,10.87,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Prominence Health Plan,NACO05,,9.61,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,,,both,,,164.33,164.33,Prominence Health Plan,NACO05,,8,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,,,both,,,33.16,33.16,Prominence Health Plan,NACO05,,3.26,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Lipid panel,80061,HCPCS,,,both,,,187.36,187.36,Prominence Health Plan,NACO05,,13.04,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,,,both,,,108.41,108.41,Prominence Health Plan,NACO05,,40.4,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Free assay (ft-3),84481,HCPCS,,,both,,,88.3,88.3,Prominence Health Plan,NACO05,,16.64,,,16.64,16.64,63.37,1 through 10,16.64,75.05,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,,,both,,,157.58,157.58,Prominence Health Plan,NACO05,,17.29,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,,,both,,,46.05,46.05,Prominence Health Plan,NACO05,,5.95,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,,,both,,,96.05,96.05,Prominence Health Plan,NACO05,,10,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Prominence Health Plan,NACO05,,9.61,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc automated,85027,HCPCS,,,both,,,86.77,86.77,Prominence Health Plan,NACO05,,6.65,,,6.65,6.65,6.65,1 through 10,6.65,6.65,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,22.13,22.13,Prominence Health Plan,NACO05,,2.31,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,,,both,,,186.84,186.84,Prominence Health Plan,NACO05,,10.87,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,,,both,,,96.05,96.05,Prominence Health Plan,NACO05,,10,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,,,both,,,46.05,46.05,Prominence Health Plan,NACO05,,5.95,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,,,both,,,40.66,40.66,Prominence Health Plan,NACO05,,5.33,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,25,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Obtaining screen pap smear,Q0091,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,42.82,,,42.82,42.82,42.82,1 through 10,42.82,42.82,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,Prominence Health Plan,NACO05,QW,2.31,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Bx done w/colposcopy add-on,58110,HCPCS,,,outpatient,,,119,119,Prominence Health Plan,NACO05,,119,,,,,,1 through 10,119,119,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,25,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,,76.07,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,outpatient,,,494,494,Prominence Health Plan,NACO05,,136.67,,,136.67,136.67,136.67,1 through 10,136.67,136.67,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,25,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Fall risk assessment docd,3288F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ptfalls assess-docd ge2>/yr,1100F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Calc bmi norm parameters,G8420,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Taking statin or rec'd order,G9664,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dschrg med/current med merge,1111F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Scr dep neg, no plan reqd",G8510,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Advnc care plan in rcrd,1157F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Pneumoc vac/admin/rcvd,4040F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Tobacco non-user,1036F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Pt on daily asa/antiplat,G9793,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,45.99,45.99,45.99,1 through 10,45.99,45.99,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,CG,98.78,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,12.23,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,108,108,Prominence Health Plan,NACO05,,30.59,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Prominence Health Plan,NACO05,CG,95.09,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,16,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Prominence Health Plan,NACO05,,60.63,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,115.24,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,Prominence Health Plan,NACO05,,123.48,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,,,outpatient,,,228,228,Prominence Health Plan,NACO05,CG,137.87,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,outpatient,,,50,50,Prominence Health Plan,NACO05,,19.87,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Depression screen annual,G0444,HCPCS,,,outpatient,,,35,35,Prominence Health Plan,NACO05,,18.56,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,both,,,17.6,17.6,Prominence Health Plan,NACO05,,0.1,,,0.1,0.1,14.41,1 through 10,0.1,16,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted pain prsnt,1125F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,Prominence Health Plan,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,Prominence Health Plan,NACO05,,15.29,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,16,16,Prominence Health Plan,NACO05,,1.1,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Blood typing serologic rh(d),86901,HCPCS,300,RC,both,,,43.41,43.41,SUPERIOR HEALTH PLAN,NACO05, ,6.02,,,6.02,6.02,6.02,1 through 10,6.02,6.02,percent of total billed charges,
Blood typing serologic abo,86900,HCPCS,300,RC,both,,,160.75,160.75,SUPERIOR HEALTH PLAN,NACO05,,6.02,,,6.02,6.02,6.02,1 through 10,6.02,6.02,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,SUPERIOR HEALTH PLAN,NACO05,,15.62,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Specimen handling pt-lab,99001,HCPCS,300,RC,outpatient,,,47.01,47.01,SUPERIOR HEALTH PLAN,NACO05,,19.2,,,19.2,19.2,19.2,1 through 10,19.2,19.2,percent of total billed charges,
Hepatitis c ab test,86803,HCPCS,302,RC,both,,,69.07,69.07,SUPERIOR HEALTH PLAN,NACO05,90,28.71,,,19.54,8.05,25.96,1 through 10,3.12,28.71,percent of total billed charges,
Hepatitis b surface ag ia,87340,HCPCS,306,RC,both,,,53.97,53.97,SUPERIOR HEALTH PLAN,NACO05,,20.78,,,20.78,20.78,20.78,1 through 10,20.78,20.78,percent of total billed charges,
Treponema pallidum,86780,HCPCS,302,RC,both,,,47.2,47.2,SUPERIOR HEALTH PLAN,NACO05,,26.64,,,22.39,18.98,25.79,1 through 10,18.13,26.64,percent of total billed charges,
Rubella antibody,86762,HCPCS,302,RC,both,,,57.56,57.56,SUPERIOR HEALTH PLAN,NACO05,,28.94,,,28.94,28.94,28.94,1 through 10,28.94,28.94,percent of total billed charges,
Hiv-1 ag w/hiv-1&-2 ab ag ia,87389,HCPCS,306,RC,both,,,63.9,63.9,SUPERIOR HEALTH PLAN,NACO05,90,48.46,,,40.72,34.53,46.91,1 through 10,32.98,48.46,percent of total billed charges,
Rbc antibody screen,86850,HCPCS,300,RC,both,,,137.37,137.37,SUPERIOR HEALTH PLAN,NACO05,,12.15,,,12.15,12.15,12.15,1 through 10,12.15,12.15,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,SUPERIOR HEALTH PLAN,NACO05,QW,4.52,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,SUPERIOR HEALTH PLAN,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Glucose test,82950,HCPCS,301,RC,both,,,23.02,23.02,SUPERIOR HEALTH PLAN,NACO05,,9.56,,,16.29,10.91,21.67,1 through 10,9.56,23.02,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,SUPERIOR HEALTH PLAN,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Chorionic gonadotropin test,84702,HCPCS,301,RC,both,,,45.38,45.38,SUPERIOR HEALTH PLAN,NACO05,,30.28,,,30.28,30.28,30.28,1 through 10,30.28,30.28,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,SUPERIOR HEALTH PLAN,NACO05,,21.24,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Metoclopramide hcl injection,J2765,HCPCS,636,RC,both,,,15,15,SUPERIOR HEALTH PLAN,NACO05,,15,,,,,,1 through 10,15,15,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,29,29,SUPERIOR HEALTH PLAN,NACO05,,17.78,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,SUPERIOR HEALTH PLAN,NACO05,,6.38,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,SUPERIOR HEALTH PLAN,NACO05,,15.62,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,15,15,SUPERIOR HEALTH PLAN,NACO05,,9.2,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,4366.46,4366.46,SUPERIOR HEALTH PLAN,NACO05,25,2678.56,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Pharmacy - IV solutions,258,RC,,,both,,,50,50,SUPERIOR HEALTH PLAN,NACO05,,30.67,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,SUPERIOR HEALTH PLAN,NACO05,,3.69,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,SUPERIOR HEALTH PLAN,NACO05,,13.87,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Chorionic gonadotropin assay,84703,HCPCS,301,RC,both,,,36.84,36.84,SUPERIOR HEALTH PLAN,NACO05,,15.13,,,10.3,10.3,14.16,1 through 10,10.3,15.13,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,SUPERIOR HEALTH PLAN,NACO05,,0.73,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Urine culture/colony count,87086,HCPCS,306,RC,both,,,69.62,69.62,SUPERIOR HEALTH PLAN,NACO05,,16.23,,,16.23,9.57,32,1 through 10,7.91,35.94,percent of total billed charges,
Strep a ag ia,87430,HCPCS,306,RC,both,,,45.04,45.04,SUPERIOR HEALTH PLAN,NACO05,QW,45.04,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,TH,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,TH,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,SUPERIOR HEALTH PLAN,NACO05,25,140,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,SUPERIOR HEALTH PLAN,NACO05,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,126,126,SUPERIOR HEALTH PLAN,NACO05,SA,248.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,,,outpatient,,,301.76,301.76,SUPERIOR HEALTH PLAN,NACO05,,60.03,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Insert needle bone cavity,36680,HCPCS,,,both,,,349.8,349.8,SUPERIOR HEALTH PLAN,NACO05,,49.4,,,49.4,49.4,49.4,1 through 10,49.4,49.4,percent of total billed charges,
Strep a ag ia,87430,HCPCS,306,RC,both,,,45.04,45.04,SUPERIOR HEALTH PLAN,NACO05,QW,33.83,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Strep a ag ia,87430,HCPCS,306,RC,both,,,45.04,45.04,SUPERIOR HEALTH PLAN,NACO05,QW,36.64,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,SUPERIOR HEALTH PLAN,NACO05,,310.92,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Feces culture aerobic bact,87045,HCPCS,306,RC,both,,,63.19,63.19,SUPERIOR HEALTH PLAN,NACO05,,37.22,,,37.22,37.22,37.22,1 through 10,37.22,37.22,percent of total billed charges,
Strep a dna amp probe,87651,HCPCS,306,RC,both,,,158.1,158.1,SUPERIOR HEALTH PLAN,NACO05,,70.6,,,70.6,70.6,70.6,1 through 10,70.6,70.6,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,SUPERIOR HEALTH PLAN,NACO05,,287.01,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Chorionic gonadotropin test,84702,HCPCS,301,RC,both,,,45.38,45.38,SUPERIOR HEALTH PLAN,NACO05,,30.28,,,30.28,30.28,30.28,1 through 10,30.28,30.28,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,SUPERIOR HEALTH PLAN,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Strep a dna amp probe,87651,HCPCS,306,RC,both,,,158.1,158.1,SUPERIOR HEALTH PLAN,NACO05,,70.6,,,70.6,70.6,70.6,1 through 10,70.6,70.6,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,SUPERIOR HEALTH PLAN,NACO05,,287.01,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Radex abdomen 1 view,74018,HCPCS,320,RC,both,,,254.34,254.34,SUPERIOR HEALTH PLAN,NACO05,,254.34,,,,,,1 through 10,254.34,254.34,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,SUPERIOR HEALTH PLAN,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,SUPERIOR HEALTH PLAN,NACO05,,314.1,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,SUPERIOR HEALTH PLAN,NACO05,,154.73,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,SUPERIOR HEALTH PLAN,NACO05,,52.79,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,SUPERIOR HEALTH PLAN,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,SUPERIOR HEALTH PLAN,NACO05,,20.42,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,SUPERIOR HEALTH PLAN,NACO05,,12.49,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,SUPERIOR HEALTH PLAN,NACO05,,22.79,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,SUPERIOR HEALTH PLAN,NACO05,,38.3,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay of free thyroxine,84439,HCPCS,301,RC,both,,,112.84,112.84,SUPERIOR HEALTH PLAN,NACO05,,35.56,,,35.56,35.56,35.56,1 through 10,11.45,35.56,percent of total billed charges,
General health panel,80050,HCPCS,301,RC,both,,,275.52,275.52,SUPERIOR HEALTH PLAN,NACO05,,99.09,,,99.09,99.09,99.09,1 through 10,99.09,99.09,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,SUPERIOR HEALTH PLAN,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Assay of protein urine,84156,HCPCS,301,RC,both,,,29.43,29.43,SUPERIOR HEALTH PLAN,NACO05,,29.43,,,,,,1 through 10,29.43,29.43,percent of total billed charges,
Fetal non-stress test,59025,HCPCS,720,RC,both,,,240,240,SUPERIOR HEALTH PLAN,NACO05,,240,,,,,,1 through 10,240,240,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,45.38,45.38,SUPERIOR HEALTH PLAN,NACO05,,45.38,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,3,3,SUPERIOR HEALTH PLAN,NACO05,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc automated,85027,HCPCS,305,RC,both,,,86.77,86.77,SUPERIOR HEALTH PLAN,NACO05,,86.77,,,6.65,6.65,6.65,1 through 10,6.65,6.65,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,SUPERIOR HEALTH PLAN,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Prev visit est age 1-4,99392,HCPCS,,,outpatient,,,150,150,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,173.77,253.83,1 through 10,120.4,253.83,percent of total billed charges,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,45.78,45.78,45.78,1 through 10,45.78,45.78,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,SUPERIOR HEALTH PLAN,NACO05,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Mmrv vaccine sc,90710,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,338.33,338.33,338.33,1 through 10,338.33,338.33,percent of total billed charges,
Hepa vacc ped/adol 2 dose im,90633,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,45.78,45.78,45.78,1 through 10,45.78,45.78,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Immune admin oral/nasal,90473,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,,,,1 through 10,54,54,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,SUPERIOR HEALTH PLAN,NACO05,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,SUPERIOR HEALTH PLAN,NACO05,25,140,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,AM,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,SUPERIOR HEALTH PLAN,NACO05,AM,253.83,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,SUPERIOR HEALTH PLAN,NACO05,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,245,245,SUPERIOR HEALTH PLAN,NACO05,AM,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Prev visit est age 1-4,99392,HCPCS,,,outpatient,,,150,150,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,173.77,253.83,1 through 10,120.4,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Hib prp-omp vacc 3 dose im,90647,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Immune admin oral/nasal,90473,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,,,,1 through 10,54,54,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,SUPERIOR HEALTH PLAN,NACO05,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,SUPERIOR HEALTH PLAN,NACO05,25,140,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Rv1 vacc 2 dose live oral,90681,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,AM,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Dtap-hep b-ipv vaccine im,90723,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,SUPERIOR HEALTH PLAN,NACO05,AM,253.83,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Immunization admin each add,90472,HCPCS,,,outpatient,,,20,20,SUPERIOR HEALTH PLAN,NACO05,,20,,,7.86,7.86,7.86,1 through 10,7.86,7.86,percent of total billed charges,
Immunization admin,90471,HCPCS,,,outpatient,,,54,54,SUPERIOR HEALTH PLAN,NACO05,,54,,,15.72,15.72,15.72,1 through 10,15.72,15.72,percent of total billed charges,
Pcv20 vaccine im,90677,HCPCS,,,outpatient,,,0.01,0.01,SUPERIOR HEALTH PLAN,NACO05,,0.01,,,306.64,306.64,306.64,1 through 10,306.64,306.64,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,245,245,SUPERIOR HEALTH PLAN,NACO05,AM,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Prev visit est age 1-4,99392,HCPCS,,,outpatient,,,150,150,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,173.77,253.83,1 through 10,120.4,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,175,175,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,TH,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Prev visit est age 1-4,99392,HCPCS,,,outpatient,,,150,150,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,173.77,253.83,1 through 10,120.4,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,175,175,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,TH,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Obstetrical care,59409,HCPCS,,,outpatient,,,3409,3409,SUPERIOR HEALTH PLAN,NACO05,U2,618.94,,,618.94,618.94,618.94,1 through 10,618.94,618.94,percent of total billed charges,
Division of fallopian tube,58605,HCPCS,,,inpatient,,,2580,2580,SUPERIOR HEALTH PLAN,NACO05,,2580,,,,,,1 through 10,2580,2580,percent of total billed charges,
Hosp ip/obs dschrg mgmt 30/<,99238,HCPCS,,,both,,,265,265,SUPERIOR HEALTH PLAN,NACO05,,265,,,,,,1 through 10,265,265,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,SUPERIOR HEALTH PLAN,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Obstetrical care,59409,HCPCS,,,outpatient,,,3409,3409,SUPERIOR HEALTH PLAN,NACO05,U2,618.94,,,618.94,618.94,618.94,1 through 10,618.94,618.94,percent of total billed charges,
Division of fallopian tube,58605,HCPCS,,,inpatient,,,2580,2580,SUPERIOR HEALTH PLAN,NACO05,,2580,,,,,,1 through 10,2580,2580,percent of total billed charges,
Hosp ip/obs dschrg mgmt 30/<,99238,HCPCS,,,both,,,265,265,SUPERIOR HEALTH PLAN,NACO05,,265,,,,,,1 through 10,265,265,percent of total billed charges,
Rem mntr physiol param 16-30,99454,HCPCS,,,outpatient,,,130,130,Texas Medicaid/Healthcare Serv,TXMD01,,130,,,47.43,47.43,47.43,1 through 10,47.43,47.43,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Texas Medicaid/Healthcare Serv,TXMD01,,103,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Texas Medicaid/Healthcare Serv,TXMD01,CG,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Texas Medicaid/Healthcare Serv,TXMD01,CG,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,Texas Medicaid/Healthcare Serv,TXMD01,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,404,404,Texas Medicaid/Healthcare Serv,TXMD01,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,105,105,Texas Medicaid/Healthcare Serv,TXMD01,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Texas Medicaid/Healthcare Serv,TXMD01,,103,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,218,218,Texas Medicaid/Healthcare Serv,TXMD01,U7,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,521,RC,outpatient,,,218,218,Texas Medicaid/Healthcare Serv,TXMD01,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,Texas Medicaid/Healthcare Serv,TXMD01,CG,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Texas Medicaid/Healthcare Serv,TXMD01,,103,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Texas Medicaid/Healthcare Serv,TXMD01,,103,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,,,outpatient,,,103,103,Texas Medicaid/Healthcare Serv,TXMD01,,103,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,21,DRG,inpatient,,,26,26,Texas Medicaid/Healthcare Serv,TXMD01,26,26,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
X-ray exam of knee 1 or 2,73560,HCPCS,22,DRG,inpatient,,,24,24,Texas Medicaid/Healthcare Serv,TXMD01,26,24,,,215,215,215,1 through 10,215,215,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,22,DRG,inpatient,,,301.76,301.76,Texas Medicaid/Healthcare Serv,TXMD01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,22,DRG,inpatient,,,498.41,498.41,Texas Medicaid/Healthcare Serv,TXMD01,,498.41,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,22,DRG,inpatient,,,31,31,Texas Medicaid/Healthcare Serv,TXMD01,26,31,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,22,DRG,inpatient,,,301.76,301.76,Texas Medicaid/Healthcare Serv,TXMD01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,22,DRG,inpatient,,,301.76,301.76,Texas Medicaid/Healthcare Serv,TXMD01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Strep a ag ia,87430,HCPCS,131,RC,inpatient,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,45.04,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,1564.24,1564.24,Texas Medicaid/Healthcare Serv,TXMD01,,366.5,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,250,RC,both,,,91.13,91.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,70.29,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,410,RC,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,23.02,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,,,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,,,both,,,15,15,Texas Medicaid/Healthcare Serv,TXMD01,,6.39,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,7.08,7.08,Texas Medicaid/Healthcare Serv,TXMD01,,3.02,,,3.02,3.02,3.02,1 through 10,3.02,3.02,percent of total billed charges,
Anes integ sys conv arrhyt,410,RC,,,outpatient,,,243.03,243.03,Texas Medicaid/Healthcare Serv,TXMD01,XU,103.53,,,103.53,103.53,103.53,1 through 10,103.53,103.53,percent of total billed charges,
N-invas ear/pls oximetry 1,94760,HCPCS,410,RC,outpatient,,,24.14,24.14,Texas Medicaid/Healthcare Serv,TXMD01,XU,10.28,,,10.28,10.28,10.28,1 through 10,10.28,10.28,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,450,RC,both,,,314.1,314.1,Texas Medicaid/Healthcare Serv,TXMD01,,109.09,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,450,RC,both,,,91.13,91.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,70.29,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,1858.58,1858.58,Texas Medicaid/Healthcare Serv,TXMD01,25,435.47,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
N.gonorrhoeae dna amp prob,87591,HCPCS,255,RC,both,,,88,88,Texas Medicaid/Healthcare Serv,TXMD01,,48.07,,,48.07,48.07,48.07,1 through 10,48.07,48.07,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,,,both,,,33.16,33.16,Texas Medicaid/Healthcare Serv,TXMD01,,4.34,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Hepatitis c ab test,86803,HCPCS,,,both,,,69.07,69.07,Texas Medicaid/Healthcare Serv,TXMD01,90,3.12,,,19.54,8.05,25.96,1 through 10,3.12,28.71,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Texas Medicaid/Healthcare Serv,TXMD01,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Chlmyd trach dna amp probe,87491,HCPCS,,,both,,,105.82,105.82,Texas Medicaid/Healthcare Serv,TXMD01,,48.07,,,48.07,48.07,48.07,1 through 10,48.07,48.07,percent of total billed charges,
Lipid panel,80061,HCPCS,,,both,,,187.36,187.36,Texas Medicaid/Healthcare Serv,TXMD01,,8.45,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,,,both,,,157.58,157.58,Texas Medicaid/Healthcare Serv,TXMD01,,23.01,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,,,both,,,164.33,164.33,Texas Medicaid/Healthcare Serv,TXMD01,,10.64,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Treponema pallidum,86780,HCPCS,,,both,,,47.2,47.2,Texas Medicaid/Healthcare Serv,TXMD01,,18.13,,,22.39,18.98,25.79,1 through 10,18.13,26.64,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,,,both,,,186.84,186.84,Texas Medicaid/Healthcare Serv,TXMD01,,8.42,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Trichomonas vaginalis amplif,87661,HCPCS,,,both,,,125.48,125.48,Texas Medicaid/Healthcare Serv,TXMD01,,48.07,,,48.07,48.07,48.07,1 through 10,48.07,48.07,percent of total billed charges,
Hiv-1 ag w/hiv-1&-2 ab ag ia,87389,HCPCS,,,both,,,63.9,63.9,Texas Medicaid/Healthcare Serv,TXMD01,90,32.98,,,40.72,34.53,46.91,1 through 10,32.98,48.46,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,,,both,,,40.66,40.66,Texas Medicaid/Healthcare Serv,TXMD01,,40.66,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,,,both,,,46.05,46.05,Texas Medicaid/Healthcare Serv,TXMD01,,46.05,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Vitamin d 25 hydroxy,82306,HCPCS,,,both,,,178.72,178.72,Texas Medicaid/Healthcare Serv,TXMD01,,178.72,,,,,,1 through 10,37.56,37.56,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,,,both,,,96.05,96.05,Texas Medicaid/Healthcare Serv,TXMD01,,13.3,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Hepatitis a antibody,86708,HCPCS,,,both,,,53.04,53.04,Texas Medicaid/Healthcare Serv,TXMD01,90,53.04,,,,,,1 through 10,53.04,53.04,percent of total billed charges,
Hep b surface antibody,86706,HCPCS,,,both,,,45.9,45.9,Texas Medicaid/Healthcare Serv,TXMD01,90,14.71,,,14.71,14.71,14.71,1 through 10,14.71,14.71,percent of total billed charges,
Hep b surface antibody,86706,HCPCS,,,both,,,45.9,45.9,Texas Medicaid/Healthcare Serv,TXMD01,90,14.71,,,14.71,14.71,14.71,1 through 10,14.71,14.71,percent of total billed charges,
Nuclear antigen antibody,86235,HCPCS,,,both,,,57.56,57.56,Texas Medicaid/Healthcare Serv,TXMD01,90,57.56,,,,,,1 through 10,57.56,57.56,percent of total billed charges,
Total cortisol,82533,HCPCS,,,both,,,79.43,79.43,Texas Medicaid/Healthcare Serv,TXMD01,90,79.43,,,,,,1 through 10,79.43,79.43,percent of total billed charges,
Assay of protein serum,84155,HCPCS,,,both,,,15.3,15.3,Texas Medicaid/Healthcare Serv,TXMD01,90,15.3,,,,,,1 through 10,15.3,15.3,percent of total billed charges,
Hepatitis c ab test,86803,HCPCS,,,both,,,60,60,Texas Medicaid/Healthcare Serv,TXMD01,90,19.54,,,19.54,8.05,25.96,1 through 10,3.12,28.71,percent of total billed charges,
H pylori (c-13) breath,83013,HCPCS,,,both,,,207.66,207.66,Texas Medicaid/Healthcare Serv,TXMD01,,207.66,,,107.19,107.19,107.19,1 through 10,107.19,107.19,percent of total billed charges,
Protein e-phoresis serum,84165,HCPCS,,,both,,,194.54,194.54,Texas Medicaid/Healthcare Serv,TXMD01,90,194.54,,,,,,1 through 10,194.54,194.54,percent of total billed charges,
Hep b core antibody total,86704,HCPCS,,,both,,,58.73,58.73,Texas Medicaid/Healthcare Serv,TXMD01,90,16.5,,,16.5,16.5,16.5,1 through 10,16.5,16.5,percent of total billed charges,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,both,,,99.51,99.51,Texas Medicaid/Healthcare Serv,TXMD01,90,99.51,,,,,,1 through 10,99.51,99.51,percent of total billed charges,
Rbc sed rate nonautomated,85651,HCPCS,,,both,,,29.43,29.43,Texas Medicaid/Healthcare Serv,TXMD01,,29.43,,,,,,1 through 10,5.41,5.41,percent of total billed charges,
Tb test cell immun measure,86480,HCPCS,,,both,,,162.36,162.36,Texas Medicaid/Healthcare Serv,TXMD01,90,162.36,,,,,,1 through 10,162.36,162.36,percent of total billed charges,
H pylori drug admin,83014,HCPCS,,,both,,,20.47,20.47,Texas Medicaid/Healthcare Serv,TXMD01,,20.47,,,10.57,10.57,10.57,1 through 10,10.57,10.57,percent of total billed charges,
Assay iga/igd/igg/igm each,82784,HCPCS,,,both,,,85.72,85.72,Texas Medicaid/Healthcare Serv,TXMD01,90,85.72,,,,,,1 through 10,85.72,85.72,percent of total billed charges,
C-reactive protein,86140,HCPCS,,,both,,,40.55,40.55,Texas Medicaid/Healthcare Serv,TXMD01,,40.55,,,,,,1 through 10,6.57,6.57,percent of total billed charges,
El-1 fecal quantitative,82653,HCPCS,,,both,,,365.58,365.58,Texas Medicaid/Healthcare Serv,TXMD01,90,365.58,,,,,,1 through 10,365.58,365.58,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,,,both,,,33.16,33.16,Texas Medicaid/Healthcare Serv,TXMD01,,4.34,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Texas Medicaid/Healthcare Serv,TXMD01,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Lactate (ld) (ldh) enzyme,83615,HCPCS,,,both,,,29.34,29.34,Texas Medicaid/Healthcare Serv,TXMD01,,29.34,,,,,,1 through 10,29.34,29.34,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,22.13,22.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,23.02,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,both,,,91.13,91.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,70.29,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,,,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,1564.24,1564.24,Texas Medicaid/Healthcare Serv,TXMD01,,366.5,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,250,RC,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Strep a ag ia,87430,HCPCS,410,RC,both,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,23.02,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,33.86,33.86,Texas Medicaid/Healthcare Serv,TXMD01,,14.42,,,14.42,14.42,14.42,1 through 10,14.42,14.42,percent of total billed charges,
Pharmacy - IV solutions,258,RC,,,both,,,50,50,Texas Medicaid/Healthcare Serv,TXMD01,,21.3,,,21.3,21.3,21.3,1 through 10,21.3,21.3,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,258,RC,both,,,186.84,186.84,Texas Medicaid/Healthcare Serv,TXMD01,,19.85,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,450,RC,both,,,164.33,164.33,Texas Medicaid/Healthcare Serv,TXMD01,,10.64,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Inj morphine pf epid ithc,J2274,HCPCS,255,RC,both,,,15,15,Texas Medicaid/Healthcare Serv,TXMD01,JZ,15,,,,,,1 through 10,15,48.94,percent of total billed charges,
Chorionic gonadotropin assay,84703,HCPCS,255,RC,both,,,36.84,36.84,Texas Medicaid/Healthcare Serv,TXMD01,,10.3,,,10.3,10.3,14.16,1 through 10,10.3,15.13,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,,,both,,,15,15,Texas Medicaid/Healthcare Serv,TXMD01,,6.39,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,3696.8,3696.8,Texas Medicaid/Healthcare Serv,TXMD01,25,1574.84,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
Ct soft tissue neck w/dye,70491,HCPCS,,,both,,,1526.02,1526.02,Texas Medicaid/Healthcare Serv,TXMD01,,220.58,,,220.58,220.58,220.58,1 through 10,220.58,220.58,percent of total billed charges,
Pharmacy - Drugs incident to radiology,255,RC,,,both,,,7.9,7.9,Texas Medicaid/Healthcare Serv,TXMD01,,3.37,,,8.5,3.37,13.63,1 through 10,3.37,13.63,percent of total billed charges,
Pharmacy - Drugs incident to radiology,255,RC,,,both,,,32,32,Texas Medicaid/Healthcare Serv,TXMD01,,13.63,,,8.5,3.37,13.63,100,3.37,13.63,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,21,DRG,inpatient,,,26,26,Texas Medicaid/Healthcare Serv,TXMD01,26,26,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
X-ray exam of knee 1 or 2,73560,HCPCS,22,DRG,inpatient,,,24,24,Texas Medicaid/Healthcare Serv,TXMD01,26,24,,,215,215,215,1 through 10,215,215,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,22,DRG,inpatient,,,301.76,301.76,Texas Medicaid/Healthcare Serv,TXMD01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,22,DRG,inpatient,,,498.41,498.41,Texas Medicaid/Healthcare Serv,TXMD01,,498.41,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,22,DRG,inpatient,,,31,31,Texas Medicaid/Healthcare Serv,TXMD01,26,31,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,22,DRG,inpatient,,,301.76,301.76,Texas Medicaid/Healthcare Serv,TXMD01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,22,DRG,inpatient,,,301.76,301.76,Texas Medicaid/Healthcare Serv,TXMD01,,301.76,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Strep a ag ia,87430,HCPCS,131,RC,inpatient,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,45.04,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,1564.24,1564.24,Texas Medicaid/Healthcare Serv,TXMD01,,366.5,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,250,RC,both,,,91.13,91.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,70.29,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,410,RC,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Strep a ag ia,87430,HCPCS,131,RC,inpatient,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,23.02,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Hepatitis a antibody,86708,HCPCS,,,both,,,53.04,53.04,Texas Medicaid/Healthcare Serv,TXMD01,90,53.04,,,,,,1 through 10,53.04,53.04,percent of total billed charges,
Hep b surface antibody,86706,HCPCS,,,both,,,45.9,45.9,Texas Medicaid/Healthcare Serv,TXMD01,90,14.71,,,14.71,14.71,14.71,1 through 10,14.71,14.71,percent of total billed charges,
Nuclear antigen antibody,86235,HCPCS,,,both,,,57.56,57.56,Texas Medicaid/Healthcare Serv,TXMD01,90,57.56,,,,,,1 through 10,57.56,57.56,percent of total billed charges,
Total cortisol,82533,HCPCS,,,both,,,79.43,79.43,Texas Medicaid/Healthcare Serv,TXMD01,90,79.43,,,,,,1 through 10,79.43,79.43,percent of total billed charges,
Assay of protein serum,84155,HCPCS,,,both,,,15.3,15.3,Texas Medicaid/Healthcare Serv,TXMD01,90,15.3,,,,,,1 through 10,15.3,15.3,percent of total billed charges,
Hepatitis c ab test,86803,HCPCS,,,both,,,60,60,Texas Medicaid/Healthcare Serv,TXMD01,90,19.54,,,19.54,8.05,25.96,1 through 10,3.12,28.71,percent of total billed charges,
H pylori (c-13) breath,83013,HCPCS,,,both,,,207.66,207.66,Texas Medicaid/Healthcare Serv,TXMD01,,207.66,,,107.19,107.19,107.19,1 through 10,107.19,107.19,percent of total billed charges,
Protein e-phoresis serum,84165,HCPCS,,,both,,,194.54,194.54,Texas Medicaid/Healthcare Serv,TXMD01,90,194.54,,,,,,1 through 10,194.54,194.54,percent of total billed charges,
Hep b core antibody total,86704,HCPCS,,,both,,,58.73,58.73,Texas Medicaid/Healthcare Serv,TXMD01,90,16.5,,,16.5,16.5,16.5,1 through 10,16.5,16.5,percent of total billed charges,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,both,,,99.51,99.51,Texas Medicaid/Healthcare Serv,TXMD01,90,99.51,,,,,,1 through 10,99.51,99.51,percent of total billed charges,
Rbc sed rate nonautomated,85651,HCPCS,,,both,,,29.43,29.43,Texas Medicaid/Healthcare Serv,TXMD01,,29.43,,,,,,1 through 10,5.41,5.41,percent of total billed charges,
Tb test cell immun measure,86480,HCPCS,,,both,,,162.36,162.36,Texas Medicaid/Healthcare Serv,TXMD01,90,162.36,,,,,,1 through 10,162.36,162.36,percent of total billed charges,
H pylori drug admin,83014,HCPCS,,,both,,,20.47,20.47,Texas Medicaid/Healthcare Serv,TXMD01,,20.47,,,10.57,10.57,10.57,1 through 10,10.57,10.57,percent of total billed charges,
Assay iga/igd/igg/igm each,82784,HCPCS,,,both,,,85.72,85.72,Texas Medicaid/Healthcare Serv,TXMD01,90,85.72,,,,,,1 through 10,85.72,85.72,percent of total billed charges,
C-reactive protein,86140,HCPCS,,,both,,,40.55,40.55,Texas Medicaid/Healthcare Serv,TXMD01,,40.55,,,,,,1 through 10,6.57,6.57,percent of total billed charges,
El-1 fecal quantitative,82653,HCPCS,,,both,,,365.58,365.58,Texas Medicaid/Healthcare Serv,TXMD01,90,365.58,,,,,,1 through 10,365.58,365.58,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,,,both,,,33.16,33.16,Texas Medicaid/Healthcare Serv,TXMD01,,4.34,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,,,both,,,12.5,12.5,Texas Medicaid/Healthcare Serv,TXMD01,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Lactate (ld) (ldh) enzyme,83615,HCPCS,,,both,,,29.34,29.34,Texas Medicaid/Healthcare Serv,TXMD01,,29.34,,,,,,1 through 10,29.34,29.34,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,22.13,22.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Strep a ag ia,87430,HCPCS,,,both,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,23.02,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,both,,,91.13,91.13,Texas Medicaid/Healthcare Serv,TXMD01,QW,70.29,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,,,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,1564.24,1564.24,Texas Medicaid/Healthcare Serv,TXMD01,,366.5,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,250,RC,both,,,355,355,Texas Medicaid/Healthcare Serv,TXMD01,,195.4,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Strep a ag ia,87430,HCPCS,410,RC,both,,,45.04,45.04,Texas Medicaid/Healthcare Serv,TXMD01,QW,23.02,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,33.86,33.86,Texas Medicaid/Healthcare Serv,TXMD01,,14.42,,,14.42,14.42,14.42,1 through 10,14.42,14.42,percent of total billed charges,
Pharmacy - IV solutions,258,RC,,,both,,,50,50,Texas Medicaid/Healthcare Serv,TXMD01,,21.3,,,21.3,21.3,21.3,1 through 10,21.3,21.3,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,258,RC,both,,,186.84,186.84,Texas Medicaid/Healthcare Serv,TXMD01,,19.85,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,450,RC,both,,,164.33,164.33,Texas Medicaid/Healthcare Serv,TXMD01,,10.64,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Inj morphine pf epid ithc,J2274,HCPCS,255,RC,both,,,15,15,Texas Medicaid/Healthcare Serv,TXMD01,JZ,15,,,,,,1 through 10,15,48.94,percent of total billed charges,
Chorionic gonadotropin assay,84703,HCPCS,255,RC,both,,,36.84,36.84,Texas Medicaid/Healthcare Serv,TXMD01,,10.3,,,10.3,10.3,14.16,1 through 10,10.3,15.13,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,,,both,,,15,15,Texas Medicaid/Healthcare Serv,TXMD01,,6.39,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Anes px clav&scapula nos,450,HCPCS,450,RC,outpatient,,,3696.8,3696.8,Texas Medicaid/Healthcare Serv,TXMD01,25,1574.84,,,366.5,366.5,1574.84,1 through 10,366.5,1574.84,percent of total billed charges,
Ct soft tissue neck w/dye,70491,HCPCS,,,both,,,1526.02,1526.02,Texas Medicaid/Healthcare Serv,TXMD01,,220.58,,,220.58,220.58,220.58,1 through 10,220.58,220.58,percent of total billed charges,
Pharmacy - Drugs incident to radiology,255,RC,,,both,,,7.9,7.9,Texas Medicaid/Healthcare Serv,TXMD01,,3.37,,,8.5,3.37,13.63,1 through 10,3.37,13.63,percent of total billed charges,
Pharmacy - Drugs incident to radiology,255,RC,,,both,,,32,32,Texas Medicaid/Healthcare Serv,TXMD01,,13.63,,,8.5,3.37,13.63,100,3.37,13.63,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UHC Surest,NACO05,,26.48,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UHC Surest,NACO05,,47,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UHC Surest,NACO05,GP,92.09,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,UHC Surest,NACO05,GP,54.91,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,UHC Surest,NACO05,GP,54.91,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UHC Surest,NACO05,GP,92.09,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,UHC Surest,NACO05,GP,54.91,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UHC Surest,NACO05,GP,92.09,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UHC Surest,NACO05,GP,92.09,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,UHC Surest,NACO05,GP,54.91,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UHC Surest,NACO05,,46.48,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
X-ray exam of knee 1 or 2,73560,HCPCS,320,RC,both,,,255.11,255.11,UHC Surest,NACO05,LT,215,,,215,215,215,1 through 10,215,215,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UHC Surest,NACO05,,46.48,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,UHC Surest,NACO05,QW,1.35,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UHC Surest,NACO05,,81.48,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Mri lower extremity w/o dye,73718,HCPCS,610,RC,both,,,2384.4,2384.4,UMR,NACO05,LT,2384.4,,,,,,1 through 10,2384.4,2384.4,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UMR,NACO05,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UMR,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Radex abdomen 3+ views,74021,HCPCS,320,RC,both,,,398.97,398.97,UMR,NACO05,,398.97,,,,,,1 through 10,398.97,398.97,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UMR,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,UMR,NACO05,,157.58,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,46.05,46.05,UMR,NACO05,,46.05,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,UMR,NACO05,,187.36,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UMR,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UMR,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UMR,NACO05,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Vitamin b-12,82607,HCPCS,301,RC,both,,,73.67,73.67,UMR,NACO05,,73.67,,,,,,1 through 10,73.67,73.67,percent of total billed charges,
Vitamin d 25 hydroxy,82306,HCPCS,301,RC,both,,,178.72,178.72,UMR,NACO05,,178.72,,,,,,1 through 10,37.56,37.56,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,UMR,NACO05,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,UMR,NACO05,,40.66,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UMR,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UMR,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,UMR,NACO05,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UMR,NACO05,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,UMR,NACO05,,187.36,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UMR,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,100,100,UMR,NACO05,25,100,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,UMR,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Triamcinolone acet inj nos,J3301,HCPCS,,,both,,,3,3,UMR,NACO05,,3,,,,,,1 through 10,3,3,percent of total billed charges,
Influenza assay w/optic,87804,HCPCS,,,both,,,32,32,UMR,NACO05,QW,32,,,,,,1 through 10,32,32,percent of total billed charges,
Strep a assay w/optic,87880,HCPCS,,,both,,,67.43,67.43,UMR,NACO05,QW,67.43,,,,,,1 through 10,67.43,67.43,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UMR,NACO05,,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,United Healthcare Insurance Co,NACO05,,85.1,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,United Healthcare Insurance Co,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Hemoglobin,85018,HCPCS,305,RC,both,,,12.27,12.27,United Healthcare Insurance Co,NACO05,,12.27,,,,,,1 through 10,12.27,12.27,percent of total billed charges,
Glucose test,82950,HCPCS,301,RC,both,,,23.02,23.02,United Healthcare Insurance Co,NACO05,,23.02,,,16.29,10.91,21.67,1 through 10,9.56,23.02,percent of total billed charges,
Hematocrit,85014,HCPCS,305,RC,both,,,12.27,12.27,United Healthcare Insurance Co,NACO05,,12.27,,,,,,1 through 10,12.27,12.27,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,United Healthcare Insurance Co,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,United Healthcare Insurance Co,NACO05,,81.48,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,United Healthcare Insurance Co,NACO05,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,,,both,,,54,54,United Healthcare Insurance Co,NACO05,,54,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,8,8,United Healthcare Insurance Co,NACO05,,8,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,,,both,,,21.13,21.13,United Healthcare Insurance Co,NACO05,QW,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,,,both,,,16,16,United Healthcare Insurance Co,NACO05,,16,,,4.43,4.43,4.43,16,4.43,5.53,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,,,both,,,8,8,United Healthcare Insurance Co,NACO05,,8,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,United Healthcare Insurance Co,NACO05,25,105,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,United Healthcare Insurance Co,NACO05,,226.42,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,United Healthcare Insurance Co,NACO05,,226.42,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,United Healthcare Insurance Co,NACO05,,106.18,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,United Healthcare Insurance Co,NACO05,,106.18,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,United Healthcare Insurance Co,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,United Healthcare Insurance Co,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Antinuclear antibodies,86038,HCPCS,302,RC,both,,,39.13,39.13,United Healthcare Insurance Co,NACO05,,39.13,,,,,,1 through 10,39.13,39.13,percent of total billed charges,
Complete cbc automated,85027,HCPCS,305,RC,both,,,86.77,86.77,United Healthcare Insurance Co,NACO05,,86.77,,,6.65,6.65,6.65,1 through 10,6.65,6.65,percent of total billed charges,
Assay of blood/uric acid,84550,HCPCS,301,RC,both,,,43.58,43.58,United Healthcare Insurance Co,NACO05,,43.58,,,,,,1 through 10,43.58,43.58,percent of total billed charges,
Assay of parathormone,83970,HCPCS,301,RC,both,,,200.3,200.3,United Healthcare Insurance Co,NACO05,,200.3,,,,,,1 through 10,52.4,52.4,percent of total billed charges,
Protein e-phoresis serum,84165,HCPCS,301,RC,both,,,194.54,194.54,United Healthcare Insurance Co,NACO05,,194.54,,,,,,1 through 10,194.54,194.54,percent of total billed charges,
Hepatitis c ab test,86803,HCPCS,302,RC,both,,,60,60,United Healthcare Insurance Co,NACO05,,60,,,19.54,8.05,25.96,1 through 10,3.12,28.71,percent of total billed charges,
Us exam abdom complete,76700,HCPCS,402,RC,both,,,655.71,655.71,United Healthcare Insurance Co,NACO05,,655.71,,,,,,1 through 10,655.71,655.71,percent of total billed charges,
Assay of magnesium,83735,HCPCS,301,RC,both,,,45.38,45.38,United Healthcare Insurance Co,NACO05,,45.38,,,,,,1 through 10,45.38,45.38,percent of total billed charges,
Assay of phosphorus,84100,HCPCS,301,RC,both,,,36.8,36.8,United Healthcare Insurance Co,NACO05,,36.8,,,,,,1 through 10,36.8,36.8,percent of total billed charges,
Hep b surface antibody,86706,HCPCS,302,RC,both,,,45.9,45.9,United Healthcare Insurance Co,NACO05,,45.9,,,14.71,14.71,14.71,1 through 10,14.71,14.71,percent of total billed charges,
Hepatitis a antibody,86708,HCPCS,302,RC,both,,,53.04,53.04,United Healthcare Insurance Co,NACO05,,53.04,,,,,,1 through 10,53.04,53.04,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,United Healthcare Insurance Co,NACO05,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Lipid panel,80061,HCPCS,301,RC,both,,,187.36,187.36,United Healthcare Insurance Co,NACO05,,13.13,,,13.12,13.05,13.12,1 through 10,8.45,159.26,percent of total billed charges,
Hep b core antibody total,86704,HCPCS,302,RC,both,,,58.73,58.73,United Healthcare Insurance Co,NACO05,,58.73,,,16.5,16.5,16.5,1 through 10,16.5,16.5,percent of total billed charges,
Nuclear antigen antibody,86235,HCPCS,301,RC,both,,,57.56,57.56,United Healthcare Insurance Co,NACO05,,57.56,,,,,,1 through 10,57.56,57.56,percent of total billed charges,
Assay of protein serum,84155,HCPCS,301,RC,both,,,15.3,15.3,United Healthcare Insurance Co,NACO05,,15.3,,,,,,1 through 10,15.3,15.3,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,United Healthcare Insurance Co,NACO05,,106.18,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,United Healthcare Insurance Co,NACO05,,305.13,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,United Healthcare Insurance Co,NACO05,,226.42,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,United Healthcare Insurance Co,NACO05,,226.42,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,339.63,339.63,United Healthcare Insurance Co,NACO05,,339.63,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,United Healthcare Insurance Co,NACO05,,106.18,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic activities,97530,HCPCS,420,RC,outpatient,,,110.51,110.51,United Healthcare Insurance Co,NACO05,,110.51,,,,,,1 through 10,110.51,110.51,percent of total billed charges,
Aquatic therapy/exercises,97113,HCPCS,420,RC,outpatient,,,305.13,305.13,United Healthcare Insurance Co,NACO05,,305.13,,,64.05,58.85,69.24,1 through 10,58.85,69.24,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,United Healthcare Insurance Co,NACO05,,226.42,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Neuromuscular reeducation,97112,HCPCS,420,RC,outpatient,,,106.18,106.18,United Healthcare Insurance Co,NACO05,,106.18,,,24.42,6.23,54.91,1 through 10,6.23,54.91,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,United Healthcare Insurance Co,NACO05,,226.42,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Syst bp ge 130 - 139mm hg,3075F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,United Healthcare Insurance Co,NACO05,,219.97,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,United Healthcare Insurance Co,NACO05,,224.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Subsequent prenatal care,0502F,HCPCS,,,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,United Healthcare Insurance Co,NACO05,,229.97,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Sys bp less 140,G8752,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Hg a1c level lt 7.0%,3044F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dschrg med/current med merge,1111F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Advnc care plan in rcrd,1157F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pt falls assess-docd le1/yr,1101F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Tobacco non-user,1036F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Taking statin or rec'd order,G9664,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Scr dep neg, no plan reqd",G8510,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fall risk assessment docd,3288F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Calc bmi abv up param f/u,G8417,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,United Healthcare Insurance Co,NACO05,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,United Healthcare Insurance Co,NACO05,,228,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,United Healthcare Insurance Co,NACO05,,229.97,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Pneumoc vac/admin/rcvd,4040F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pt on daily asa/antiplat,G9793,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,45.99,45.99,45.99,1 through 10,45.99,45.99,percent of total billed charges,
Ct head/brain w/o dye,70450,HCPCS,350,RC,both,,,1469.28,1469.28,United Healthcare Insurance Co,NACO05,,20.9,,,25.64,20.9,56.16,1 through 10,20.9,67.21,percent of total billed charges,
Us compl joint r-t w/img,76881,HCPCS,402,RC,both,,,449.14,449.14,United Healthcare Insurance Co,NACO05,RT,52.49,,,52.49,52.49,52.49,1 through 10,52.49,52.49,percent of total billed charges,
Ct thorax dx c-,71250,HCPCS,350,RC,both,,,1831.63,1831.63,United Healthcare Insurance Co,NACO05,,104.51,,,102.18,82.43,104.51,1 through 10,74.97,104.51,percent of total billed charges,
Strep a ag ia,87430,HCPCS,306,RC,both,,,45.04,45.04,United Healthcare Insurance Co,NACO05,,45.04,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,521,RC,outpatient,,,105,105,United Healthcare Insurance Co,NACO05,,224.97,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Subsequent prenatal care,0502F,HCPCS,,,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,United Healthcare Insurance Co,NACO05,,229.97,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Sys bp less 140,G8752,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Hg a1c level lt 7.0%,3044F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dschrg med/current med merge,1111F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Advnc care plan in rcrd,1157F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pt falls assess-docd le1/yr,1101F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Tobacco non-user,1036F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Taking statin or rec'd order,G9664,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Scr dep neg, no plan reqd",G8510,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fall risk assessment docd,3288F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Calc bmi abv up param f/u,G8417,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,United Healthcare Insurance Co,NACO05,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,United Healthcare Insurance Co,NACO05,,228,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,United Healthcare Insurance Co,NACO05,,229.97,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Pneumoc vac/admin/rcvd,4040F,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pt on daily asa/antiplat,G9793,HCPCS,521,RC,outpatient,,,0.01,0.01,United Healthcare Insurance Co,NACO05,,0.01,,,45.99,45.99,45.99,1 through 10,45.99,45.99,percent of total billed charges,
Ct head/brain w/o dye,70450,HCPCS,350,RC,both,,,1469.28,1469.28,United Healthcare Insurance Co,NACO05,,20.9,,,25.64,20.9,56.16,1 through 10,20.9,67.21,percent of total billed charges,
Us compl joint r-t w/img,76881,HCPCS,402,RC,both,,,449.14,449.14,United Healthcare Insurance Co,NACO05,RT,52.49,,,52.49,52.49,52.49,1 through 10,52.49,52.49,percent of total billed charges,
Ct thorax dx c-,71250,HCPCS,350,RC,both,,,1831.63,1831.63,United Healthcare Insurance Co,NACO05,,104.51,,,102.18,82.43,104.51,1 through 10,74.97,104.51,percent of total billed charges,
Strep a ag ia,87430,HCPCS,306,RC,both,,,45.04,45.04,United Healthcare Insurance Co,NACO05,,45.04,,,12.11,12.11,15.13,1 through 10,11.77,36.64,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,United of Omaha Life Insurance,NACO05,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Laboratory - Bacteriology and Microbiology,306,RC,,,both,,,355,355,UnitedHealthcare,NACO05,,355,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UnitedHealthcare,NACO05,,56.6,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Transvaginal us non-ob,76830,HCPCS,,,both,,,96,96,UnitedHealthcare,NACO05,26,28.31,,,29.75,28.6,30.9,1 through 10,28.31,31.19,percent of total billed charges,
Us exam pelvic complete,76856,HCPCS,,,both,,,95,95,UnitedHealthcare,NACO05,26,28.02,,,29.61,28.34,30.87,1 through 10,28.02,31.19,percent of total billed charges,
H pylori (c-13) breath,83013,HCPCS,300,RC,both,,,207.66,207.66,UnitedHealthcare,NACO05,,107.19,,,107.19,107.19,107.19,1 through 10,107.19,107.19,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO05,,6.45,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO05,,17.12,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Assay of amylase,82150,HCPCS,301,RC,both,,,58.88,58.88,UnitedHealthcare,NACO05,,30.39,,,30.39,30.39,30.39,1 through 10,30.39,30.39,percent of total billed charges,
H pylori drug admin,83014,HCPCS,300,RC,both,,,20.47,20.47,UnitedHealthcare,NACO05,,10.57,,,10.57,10.57,10.57,1 through 10,10.57,10.57,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO05,,84.83,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO05,,96.44,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urine culture/colony count,87086,HCPCS,306,RC,both,,,69.62,69.62,UnitedHealthcare,NACO05,,35.94,,,16.23,9.57,32,1 through 10,7.91,35.94,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO05,,34.07,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Prp i/hern init block >5 yr,49507,HCPCS,,,outpatient,,,1725,1725,UnitedHealthcare,NACO05,,1725,,,,,,1 through 10,1725,1725,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO05,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Other Imaging Services - Ultrasound,402,RC,,,both,,,596.1,596.1,UnitedHealthcare,NACO05,,139.02,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Other Imaging Services - Ultrasound,402,RC,,,both,,,666.19,666.19,UnitedHealthcare,NACO05,,155.38,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UnitedHealthcare,NACO05,,46.48,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Laboratory - Chemistry,301,RC,,,both,,,186.84,186.84,UnitedHealthcare,NACO05,,186.84,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Chemistry,301,RC,,,both,,,157.58,157.58,UnitedHealthcare,NACO05,,157.58,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Bacteriology and Microbiology,306,RC,,,both,,,69.62,69.62,UnitedHealthcare,NACO05,,69.62,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Bacteriology and Microbiology,306,RC,,,both,,,66.07,66.07,UnitedHealthcare,NACO05,,66.07,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Chemistry,301,RC,,,both,,,96.05,96.05,UnitedHealthcare,NACO05,,96.05,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Bacteriology and Microbiology,306,RC,,,both,,,37.36,37.36,UnitedHealthcare,NACO05,,37.36,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Hematology,305,RC,,,both,,,164.33,164.33,UnitedHealthcare,NACO05,,164.33,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Chemistry,301,RC,,,both,,,187.36,187.36,UnitedHealthcare,NACO05,,187.36,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,12.5,12.5,UnitedHealthcare,NACO05,,12.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Urology,307,RC,,,both,,,33.16,33.16,UnitedHealthcare,NACO05,,33.16,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,45.99,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Depression screen annual,G0444,HCPCS,521,RC,outpatient,,,35,35,UnitedHealthcare,NACO12,,35,,,18.56,18.56,187.69,1 through 10,18.56,229.97,percent of total billed charges,
Pt on daily asa/antiplat,G9793,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,45.99,,,45.99,45.99,45.99,1 through 10,45.99,45.99,percent of total billed charges,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,521,RC,outpatient,,,50,50,UnitedHealthcare,NACO12,,50,,,19.87,19.87,19.87,1 through 10,19.87,19.87,percent of total billed charges,
Taking statin or rec'd order,G9664,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Pneumoc vac/admin/rcvd,4040F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Colorectal ca screen doc rev,3017F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Sys bp less 140,G8752,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Calc bmi abv up param f/u,G8417,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Scr dep neg, no plan reqd",G8510,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fall risk assessment docd,3288F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Ptfalls assess-docd ge2>/yr,1100F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Hemoglobin a1c level >9.0%,3046F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Dschrg med/current med merge,1111F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Tobacco non-user,1036F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Advnc care plan in rcrd,1157F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
"Ppps, subseq visit",G0439,HCPCS,521,RC,outpatient,,,228,228,UnitedHealthcare,NACO12,25,228,,,218.04,137.87,218.04,1 through 10,137.87,225.37,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,521,RC,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Manual therapy 1/> regions,97140,HCPCS,420,RC,outpatient,,,103.23,103.23,UnitedHealthcare,NACO12,GP,4.06,,,4.06,4.06,4.06,1 through 10,4.06,15.93,percent of total billed charges,
Therapeutic exercises,97110,HCPCS,420,RC,outpatient,,,226.42,226.42,UnitedHealthcare,NACO12,GP,9.89,,,33.6,8.62,56.18,1 through 10,8.57,92.09,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,50.46,50.46,UnitedHealthcare,NACO12,,50.46,,,3.02,3.02,3.02,1 through 10,3.02,3.02,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Urine culture/colony count,87086,HCPCS,306,RC,both,,,69.62,69.62,UnitedHealthcare,NACO12,,69.62,,,16.23,9.57,32,1 through 10,7.91,35.94,percent of total billed charges,
Radex abdomen 1 view,74018,HCPCS,320,RC,both,,,254.34,254.34,UnitedHealthcare,NACO12,,254.34,,,,,,1 through 10,254.34,254.34,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,50,50,UnitedHealthcare,NACO12,,50,,,,,,1 through 10,50,100,percent of total billed charges,
Hydration iv infusion init,96360,HCPCS,450,RC,outpatient,,,771.33,771.33,UnitedHealthcare,NACO12,,771.33,,,208.38,208.38,208.38,1 through 10,208.38,927.64,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,150.34,150.34,UnitedHealthcare,NACO12,,150.34,,,3.02,3.02,3.02,1 through 10,3.02,3.02,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,30.12,30.12,UnitedHealthcare,NACO12,,30.12,,,3.02,3.02,3.02,1 through 10,3.02,3.02,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3.33,3.33,UnitedHealthcare,NACO12,,3.33,,,3.02,3.02,3.02,1 through 10,3.02,3.02,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ct thorax dx c-,71250,HCPCS,350,RC,both,,,1831.63,1831.63,UnitedHealthcare,NACO12,,99.85,,,102.18,82.43,104.51,1 through 10,74.97,104.51,percent of total billed charges,
X-ray exam neck spine 2-3 vw,72040,HCPCS,320,RC,both,,,317.92,317.92,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,16.54,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,292.79,292.79,UnitedHealthcare,NACO12,LT,82.68,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
X-ray exam hip uni 1 view,73501,HCPCS,320,RC,both,,,220.78,220.78,UnitedHealthcare,NACO12,LT,220.78,,,,,,1 through 10,220.78,220.78,percent of total billed charges,
X-ray exam of femur 2/>,73552,HCPCS,320,RC,both,,,264.93,264.93,UnitedHealthcare,NACO12,LT,264.93,,,,,,1 through 10,264.93,264.93,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Amnt pain noted none prsnt,1126F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,105,105,UnitedHealthcare,NACO12,,83.17,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Diast bp >= 90 mm hg,3080F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Fxnl status assessed,1170F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp lt 130 mm hg,3074F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Diast bp 80-89 mm hg,3079F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Syst bp >= 140 mm hg,3077F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Diast bp <80 mm hg,3078F,HCPCS,,,outpatient,,,0.01,0.01,UnitedHealthcare,NACO12,,0.01,,,,,,1 through 10,0.01,0.01,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,1026.3,1026.3,UnitedHealthcare,NACO12,,1026.3,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Tx/pro/dx inj new drug addon,96375,HCPCS,450,RC,outpatient,,,334.83,334.83,UnitedHealthcare,NACO12,,334.83,,,41.29,37.62,44.95,1 through 10,36.7,45.87,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,26.24,26.24,UnitedHealthcare,NACO12,,26.24,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.06,4.06,UnitedHealthcare,NACO12,,4.06,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,UnitedHealthcare,NACO12,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,UnitedHealthcare,NACO12,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,25.5,25.5,UnitedHealthcare,NACO12,,25.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,4.32,4.32,UnitedHealthcare,NACO12,,4.32,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,UnitedHealthcare,NACO12,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,UnitedHealthcare,NACO12,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Emergency dept visit mod mdm,99284,HCPCS,450,RC,outpatient,,,2542.21,2542.21,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,46.2,2678.56,percent of total billed charges,
Creatine mb fraction,82553,HCPCS,301,RC,both,,,62.03,62.03,UnitedHealthcare,NACO12,,62.03,,,,,,1 through 10,62.03,62.03,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,UnitedHealthcare,NACO12,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,UnitedHealthcare,NACO12,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Fibrin degradation quant,85379,HCPCS,305,RC,both,,,122.65,122.65,UnitedHealthcare,NACO12,,122.65,,,,,,1 through 10,122.65,122.65,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,32,32,UnitedHealthcare,NACO12,QN,32,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,UnitedHealthcare,NACO12,QN,294.6,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,UnitedHealthcare,NACO12,,22.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,UnitedHealthcare,NACO12,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
X-ray exam of knee 3,73562,HCPCS,320,RC,both,,,585.58,585.58,UnitedHealthcare,NACO12,50,585.58,,,82.68,82.68,82.68,1 through 10,82.68,82.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,277,277,UnitedHealthcare,NACO12,,277,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Chrnc care mgmt staff 1st 20,99490,HCPCS,521,RC,outpatient,,,103,103,UnitedHealthcare,NACO12,,12.1,,,47.42,12.1,47.42,1 through 10,12.1,229.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,,,outpatient,,,126,126,UnitedHealthcare,NACO12,,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,UnitedHealthcare,NACO12,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,450,RC,both,,,588.68,588.68,UnitedHealthcare,NACO12,,588.68,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,UnitedHealthcare,NACO12,25,115,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Dexamethasone sodium phos,J1100,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,5.32,5.32,5.32,12,5.32,6.39,percent of total billed charges,
Ketorolac tromethamine inj,J1885,HCPCS,636,RC,both,,,21.6,21.6,UnitedHealthcare,NACO12,,21.6,,,1.1,1.1,1.1,1 through 10,1.1,2.76,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,UnitedHealthcare,NACO12,,16.54,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,UnitedHealthcare,NACO12,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,UnitedHealthcare,NACO12,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
"Inj, acetaminophen (b braun)",J0136,HCPCS,636,RC,both,,,29.16,29.16,UnitedHealthcare,NACO12,,29.16,,,0.73,0.73,0.73,1 through 10,0.73,0.73,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,450,RC,outpatient,,,804.85,804.85,UnitedHealthcare,NACO12,,804.85,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
Assay of lipase,83690,HCPCS,301,RC,both,,,66.01,66.01,UnitedHealthcare,NACO12,,66.01,,,23.97,15.89,32.05,1 through 10,13.87,34.07,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,UnitedHealthcare,NACO12,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,UnitedHealthcare,NACO12,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,100,100,UnitedHealthcare,NACO12,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Ct abd & pelvis w/o contrast,74176,HCPCS,350,RC,both,,,2009.12,2009.12,UnitedHealthcare,NACO12,,2009.12,,,62.2,62.2,62.2,1 through 10,62.2,62.2,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,450,RC,outpatient,,,295.66,295.66,UnitedHealthcare,NACO12,,295.66,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,306.61,306.61,UnitedHealthcare,NACO12,,306.61,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,UnitedHealthcare,NACO12,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,UnitedHealthcare,NACO12,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,30,30,UnitedHealthcare,NACO12,,30,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,UnitedHealthcare,NACO12,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,8.89,8.89,UnitedHealthcare,NACO12,,8.89,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,UnitedHealthcare,NACO12,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,126,126,WELLCARE OF TEXAS INC.,NACO08,CG,126,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Ur albumin quantitative,82043,HCPCS,301,RC,both,,,43.96,43.96,WELLCARE OF TEXAS INC.,NACO08,,43.96,,,5.81,5.66,11,1 through 10,5.66,22.79,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,21.13,21.13,WELLCARE OF TEXAS INC.,NACO08,,21.13,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,178.37,178.37,WELLCARE OF TEXAS INC.,NACO08,,178.37,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,91.69,91.69,WELLCARE OF TEXAS INC.,NACO08,,91.69,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,150.43,150.43,WELLCARE OF TEXAS INC.,NACO08,,150.43,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Assay of urine creatinine,82570,HCPCS,301,RC,both,,,40.66,40.66,WELLCARE OF TEXAS INC.,NACO08,,40.66,,,5.21,5.08,9.86,1 through 10,5.08,20.42,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,11.93,11.93,WELLCARE OF TEXAS INC.,NACO08,,11.93,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,156.88,156.88,WELLCARE OF TEXAS INC.,NACO08,,156.88,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,120,120,WELLCARE OF TEXAS INC.,NACO08,CG,120,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Office o/p est mod 30 min,99214,HCPCS,521,RC,outpatient,,,120,120,WELLCARE OF TEXAS INC.,NACO08,CG,120,,,78.96,75.65,174.43,1 through 10,25.2,219.97,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,,,outpatient,,,301.76,301.76,WELLPOINT INSURANCE COMPANY,NACO05,,30.65,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Per pm reeval est pat infant,99391,HCPCS,,,outpatient,,,140,140,WELLPOINT INSURANCE COMPANY,NACO05,,140,,,183.24,112.64,253.83,1 through 10,112.64,253.83,percent of total billed charges,
Vitamin b12 injection,J3420,HCPCS,,,both,,,16,16,WELLPOINT INSURANCE COMPANY,NACO05,,16,,,,,,1 through 10,16,16,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,,,outpatient,,,126,126,WELLPOINT INSURANCE COMPANY,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,,,outpatient,,,126,126,WELLPOINT INSURANCE COMPANY,NACO05,SA,253.83,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Laboratory - Hematology,305,RC,,,both,,,821.65,821.65,WELLPOINT INSURANCE COMPANY,NACO05,,821.65,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - General,300,RC,,,both,,,62.5,62.5,WELLPOINT INSURANCE COMPANY,NACO05,,62.5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Emergency room - General,450,RC,,,outpatient,,,1564.24,1564.24,WELLPOINT INSURANCE COMPANY,NACO05,,1564.24,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Room and Board Semi-private (two beds) - General,120,RC,,,inpatient,,,4300,4300,WELLPOINT INSURANCE COMPANY,NACO05,,18135.46,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pulmonary Function - General,460,RC,,,outpatient,,,77.86,77.86,WELLPOINT INSURANCE COMPANY,NACO05,,77.86,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Bacteriology and Microbiology,306,RC,,,both,,,446.13,446.13,WELLPOINT INSURANCE COMPANY,NACO05,,446.13,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - IV solutions,258,RC,,,both,,,350,350,WELLPOINT INSURANCE COMPANY,NACO05,,350,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,12,12,WELLPOINT INSURANCE COMPANY,NACO05,,12,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,WELLPOINT INSURANCE COMPANY,NACO05,,5,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Laboratory - Chemistry,301,RC,,,both,,,1204.25,1204.25,WELLPOINT INSURANCE COMPANY,NACO05,,1204.25,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,675.4,675.4,WELLPOINT INSURANCE COMPANY,NACO05,,675.4,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Radiology Diagnostic - General,320,RC,,,both,,,231.45,231.45,WELLPOINT INSURANCE COMPANY,NACO05,,231.45,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,761,RC,outpatient,,,348,348,WELLPOINT INSURANCE COMPANY,NACO05,,348,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Hydration iv infusion init,96360,HCPCS,761,RC,both,,,731.01,731.01,WELLPOINT INSURANCE COMPANY,NACO05,59,927.64,,,208.38,208.38,208.38,1 through 10,208.38,927.64,percent of total billed charges,
Assay of ferritin,82728,HCPCS,301,RC,both,,,71.14,71.14,WELLPOINT INSURANCE COMPANY,NACO05,,17.29,,,,,,1 through 10,17.29,17.29,percent of total billed charges,
Vitamin d 25 hydroxy,82306,HCPCS,301,RC,both,,,178.72,178.72,WELLPOINT INSURANCE COMPANY,NACO05,,37.56,,,,,,1 through 10,37.56,37.56,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,5,5,WELLPOINT INSURANCE COMPANY,NACO05,,6.35,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of progesterone,84144,HCPCS,301,RC,both,,,101.3,101.3,WELLPOINT INSURANCE COMPANY,NACO05,90,26.48,,,,,,1 through 10,26.48,26.48,percent of total billed charges,
Assay of parathormone,83970,HCPCS,301,RC,both,,,200.3,200.3,WELLPOINT INSURANCE COMPANY,NACO05,90,52.4,,,,,,1 through 10,52.4,52.4,percent of total billed charges,
Normal saline solution infus,J7030,HCPCS,258,RC,both,,,100,100,WELLPOINT INSURANCE COMPANY,NACO05,,100,,,,,,1 through 10,50,100,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,20,20,WELLPOINT INSURANCE COMPANY,NACO05,,25.38,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,WELLPOINT INSURANCE COMPANY,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,761,RC,both,,,265.06,265.06,WELLPOINT INSURANCE COMPANY,NACO05,,336.37,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Assay of free thyroxine,84439,HCPCS,301,RC,both,,,112.84,112.84,WELLPOINT INSURANCE COMPANY,NACO05,,11.45,,,35.56,35.56,35.56,1 through 10,11.45,35.56,percent of total billed charges,
Assay of free thyroxine,84439,HCPCS,301,RC,both,,,112.84,112.84,WELLPOINT INSURANCE COMPANY,NACO05,,11.45,,,35.56,35.56,35.56,1 through 10,11.45,35.56,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT INSURANCE COMPANY,NACO05,,13.4,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,WELLPOINT INSURANCE COMPANY,NACO05,,180.99,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT INSURANCE COMPANY,NACO05,,9.87,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,WELLPOINT INSURANCE COMPANY,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,WELLPOINT INSURANCE COMPANY,NACO05,,4.03,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,WELLPOINT INSURANCE COMPANY,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Urine culture/colony count,87086,HCPCS,306,RC,both,,,69.62,69.62,WELLPOINT INSURANCE COMPANY,NACO05,,10.24,,,16.23,9.57,32,1 through 10,7.91,35.94,percent of total billed charges,
Assay thyroid stim hormone,84443,HCPCS,301,RC,both,,,157.58,157.58,WELLPOINT INSURANCE COMPANY,NACO05,,21.32,,,16.46,16.46,17.29,1 through 10,16.46,133.94,percent of total billed charges,
Urinalysis auto w/o scope,81003,HCPCS,307,RC,both,,,22.13,22.13,WELLPOINT INSURANCE COMPANY,NACO05,59,2.85,,,2.2,1.59,5.95,1 through 10,1.35,18.81,percent of total billed charges,
C-reactive protein,86140,HCPCS,302,RC,both,,,40.55,40.55,WELLPOINT INSURANCE COMPANY,NACO05,,6.57,,,,,,1 through 10,6.57,6.57,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,WELLPOINT INSURANCE COMPANY,NACO05,,49.83,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Rbc sed rate nonautomated,85651,HCPCS,305,RC,both,,,29.43,29.43,WELLPOINT INSURANCE COMPANY,NACO05,,5.41,,,,,,1 through 10,5.41,5.41,percent of total billed charges,
Prothrombin time,85610,HCPCS,305,RC,both,,,42.02,42.02,WELLPOINT INSURANCE COMPANY,NACO05,,5.44,,,,,,1 through 10,5.44,5.44,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT INSURANCE COMPANY,NACO05,,9.87,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,WELLPOINT INSURANCE COMPANY,NACO05,,307.63,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT INSURANCE COMPANY,NACO05,,13.4,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT INSURANCE COMPANY,NACO05,,9.87,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,WELLPOINT INSURANCE COMPANY,NACO05,,307.63,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT INSURANCE COMPANY,NACO05,,13.4,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT INSURANCE COMPANY,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,WELLPOINT INSURANCE COMPANY,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,3,3,WELLPOINT INSURANCE COMPANY,NACO05,,3,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
X-ray exam chest 2 views,71046,HCPCS,320,RC,both,,,314.1,314.1,WELLPOINT INSURANCE COMPANY,NACO05,,314.1,,,16.54,16.54,16.54,1 through 10,16.54,307.63,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,WELLPOINT INSURANCE COMPANY,NACO05,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT INSURANCE COMPANY,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,WELLPOINT INSURANCE COMPANY,NACO05,25,146.64,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,WELLPOINT INSURANCE COMPANY,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,WELLPOINT INSURANCE COMPANY,NACO05,,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,306,RC,both,,,91.13,91.13,WELLPOINT INSURANCE COMPANY,NACO05,,91.13,,,70.29,50.28,70.29,1 through 10,50.28,70.29,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,WELLPOINT INSURANCE COMPANY,NACO05,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,450,RC,outpatient,,,1564.24,1564.24,WELLPOINT INSURANCE COMPANY,NACO05,,146.64,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT INSURANCE COMPANY,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT INSURANCE COMPANY,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Office o/p est low 20 min,99213,HCPCS,,,outpatient,,,220,220,WELLPOINT INSURANCE COMPANY,NACO05,,18.74,,,57.58,26.97,174.43,1 through 10,18.11,224.97,percent of total billed charges,
Emergency dept visit low mdm,99283,HCPCS,,,outpatient,,,301.76,301.76,WELLPOINT INSURANCE COMPANY,NACO05,,33.31,,,115,115,115,1 through 10,0.78,154.71,percent of total billed charges,
"Clinic visit/encounter, all-inclusive",T1015,HCPCS,,,outpatient,,,167,167,WELLPOINT TEXAS INC.,NACO05,,167,,,253.83,253.83,253.83,1 through 10,248.83,253.83,percent of total billed charges,
Ground mileage,A0425,HCPCS,540,RC,outpatient,,,36,36,WELLPOINT TEXAS INC.,NACO05,QN,36,,,30.47,16.73,342.27,1 through 10,13.3,420.22,percent of total billed charges,
Als1-emergency,A0427,HCPCS,540,RC,outpatient,,,1378.57,1378.57,WELLPOINT TEXAS INC.,NACO05,QN,1378.57,,,294.6,294.6,294.6,1 through 10,294.6,516.16,percent of total billed charges,
Normal saline solution infus,J7050,HCPCS,258,RC,both,,,50,50,WELLPOINT TEXAS INC.,NACO05,,50,,,,,,1 through 10,50,50,percent of total billed charges,
Ringers lactate infusion,J7120,HCPCS,258,RC,both,,,50,50,WELLPOINT TEXAS INC.,NACO05,,50,,,,,,1 through 10,50,100,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,15,15,WELLPOINT TEXAS INC.,NACO05,,15,,,4.43,4.43,4.43,1 through 10,4.43,5.53,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT TEXAS INC.,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ciprofloxacin iv,J0744,HCPCS,636,RC,both,,,25.16,25.16,WELLPOINT TEXAS INC.,NACO05,,25.16,,,,,,1 through 10,25.16,25.16,percent of total billed charges,
Medical/Surgical Supplies and Devices - Sterile,272,RC,,,both,,,97,97,WELLPOINT TEXAS INC.,NACO05,,97,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Assay of natriuretic peptide,83880,HCPCS,301,RC,both,,,108.41,108.41,WELLPOINT TEXAS INC.,NACO05,,108.41,,,38.47,38.47,38.86,1 through 10,38.47,154.73,percent of total billed charges,
Inj potassium chloride,J3480,HCPCS,636,RC,both,,,50,50,WELLPOINT TEXAS INC.,NACO05,,50,,,,,,1 through 10,50,50,percent of total billed charges,
Strep a dna amp probe,87651,HCPCS,306,RC,both,,,158.1,158.1,WELLPOINT TEXAS INC.,NACO05,,158.1,,,70.6,70.6,70.6,1 through 10,70.6,70.6,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT TEXAS INC.,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Assay of ck (cpk),82550,HCPCS,301,RC,both,,,108.02,108.02,WELLPOINT TEXAS INC.,NACO05,,108.02,,,,,,1 through 10,108.02,108.02,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,450,RC,outpatient,,,513.15,513.15,WELLPOINT TEXAS INC.,NACO05,,513.15,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Hemoglobin glycosylated a1c,83036,HCPCS,301,RC,both,,,96.05,96.05,WELLPOINT TEXAS INC.,NACO05,,96.05,,,9.52,9.52,23.3,1 through 10,9.52,81.64,percent of total billed charges,
Emergency dept visit hi mdm,99285,HCPCS,450,RC,outpatient,,,3694.88,3694.88,WELLPOINT TEXAS INC.,NACO05,25,2348.25,,,112.41,112.41,112.41,1 through 10,112.41,2348.25,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,WELLPOINT TEXAS INC.,NACO05,,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,12.5,12.5,WELLPOINT TEXAS INC.,NACO05,,12.5,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Urine culture/colony count,87086,HCPCS,306,RC,both,,,69.62,69.62,WELLPOINT TEXAS INC.,NACO05,,69.62,,,16.23,9.57,32,1 through 10,7.91,35.94,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,450,RC,outpatient,,,613.22,613.22,WELLPOINT TEXAS INC.,NACO05,XU,613.22,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Inj potassium chloride,J3480,HCPCS,636,RC,both,,,50,50,WELLPOINT TEXAS INC.,NACO05,,50,,,,,,1 through 10,50,50,percent of total billed charges,
Procalcitonin (pct),84145,HCPCS,301,RC,both,,,130.08,130.08,WELLPOINT TEXAS INC.,NACO05,,130.08,,,,,,1 through 10,130.08,130.08,percent of total billed charges,
Resp virus 3-5 targets,87631,HCPCS,306,RC,both,,,355,355,WELLPOINT TEXAS INC.,NACO05,,355,,,195.4,195.4,287.01,1 through 10,47,310.92,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,760,RC,both,,,1325.3,1325.3,WELLPOINT TEXAS INC.,NACO05,,1325.3,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Glucose blood test,82962,HCPCS,301,RC,both,,,16.4,16.4,WELLPOINT TEXAS INC.,NACO05,,16.4,,,,,,1 through 10,16.4,16.4,percent of total billed charges,
Blood culture for bacteria,87040,HCPCS,306,RC,both,,,107.81,107.81,WELLPOINT TEXAS INC.,NACO05,,107.81,,,,,,1 through 10,107.81,107.81,percent of total billed charges,
Medical/Surgical Supplies and Devices - Nonsterile,271,RC,,,both,,,6,6,WELLPOINT TEXAS INC.,NACO05,,6,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Ther/proph/diag iv inf addon,96366,HCPCS,760,RC,both,,,476.14,476.14,WELLPOINT TEXAS INC.,NACO05,,476.14,,,,,,1 through 10,295.66,476.14,percent of total billed charges,
Electrocardiogram tracing,93005,HCPCS,730,RC,both,,,103.03,103.03,WELLPOINT TEXAS INC.,NACO05,XU,103.03,,,11.8,11.8,11.8,1 through 10,11.8,11.8,percent of total billed charges,
Complete cbc w/auto diff wbc,85025,HCPCS,305,RC,both,,,164.33,164.33,WELLPOINT TEXAS INC.,NACO05,,164.33,,,8,7.61,57.15,1 through 10,7.61,139.68,percent of total billed charges,
Tx/pro/dx inj same drug adon,96376,HCPCS,760,RC,both,,,278.01,278.01,WELLPOINT TEXAS INC.,NACO05,,278.01,,,,,,1 through 10,278.01,278.01,percent of total billed charges,
Blood culture for bacteria,87040,HCPCS,306,RC,both,,,107.81,107.81,WELLPOINT TEXAS INC.,NACO05,91,107.81,,,,,,1 through 10,107.81,107.81,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,WELLPOINT TEXAS INC.,NACO05,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Assay of troponin quant,84484,HCPCS,301,RC,both,,,88.25,88.25,WELLPOINT TEXAS INC.,NACO05,91,88.25,,,,,,1 through 10,88.25,88.25,percent of total billed charges,
X-ray exam chest 1 view,71045,HCPCS,320,RC,both,,,231.45,231.45,WELLPOINT TEXAS INC.,NACO05,,231.45,,,45.89,14.39,77.38,1 through 10,6.52,85.25,percent of total billed charges,
Tx/proph/dg addl seq iv inf,96367,HCPCS,760,RC,both,,,392.27,392.27,WELLPOINT TEXAS INC.,NACO05,,392.27,,,,,,1 through 10,392.27,392.27,percent of total billed charges,
Ther/proph/diag inj sc/im,96372,HCPCS,760,RC,both,,,283.33,283.33,WELLPOINT TEXAS INC.,NACO05,,283.33,,,15.93,15.93,348.86,1 through 10,12.23,348.86,percent of total billed charges,
Ciprofloxacin iv,J0744,HCPCS,636,RC,both,,,25.16,25.16,WELLPOINT TEXAS INC.,NACO05,,25.16,,,,,,1 through 10,25.16,25.16,percent of total billed charges,
Ther/proph/diag iv inf init,96365,HCPCS,760,RC,both,,,708.59,708.59,WELLPOINT TEXAS INC.,NACO05,,708.59,,,166.69,166.69,166.69,1 through 10,166.69,166.69,percent of total billed charges,
C-reactive protein,86140,HCPCS,302,RC,both,,,40.55,40.55,WELLPOINT TEXAS INC.,NACO05,,40.55,,,,,,1 through 10,6.57,6.57,percent of total billed charges,
Insert temp bladder cath,51702,HCPCS,450,RC,outpatient,,,627.81,627.81,WELLPOINT TEXAS INC.,NACO05,,627.81,,,,,,1 through 10,627.81,627.81,percent of total billed charges,
Hydrate iv infusion add-on,96361,HCPCS,760,RC,both,,,2915.66,2915.66,WELLPOINT TEXAS INC.,NACO05,,2915.66,,,,,,1 through 10,336.37,336.37,percent of total billed charges,
Coll venous bld venipuncture,36415,HCPCS,300,RC,both,,,25,25,WELLPOINT TEXAS INC.,NACO05,,25,,,9.15,9.15,17.15,1 through 10,6.45,18.31,percent of total billed charges,
Ther/proph/diag inj iv push,96374,HCPCS,760,RC,both,,,511.23,511.23,WELLPOINT TEXAS INC.,NACO05,59,511.23,,,208.38,208.38,208.38,1 through 10,208.38,208.38,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,22.57,22.57,WELLPOINT TEXAS INC.,NACO05,,22.57,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Culture aerobic identify,87077,HCPCS,306,RC,both,,,37.36,37.36,WELLPOINT TEXAS INC.,NACO05,,37.36,,,7.92,7.92,7.92,1 through 10,7.92,7.92,percent of total billed charges,
Sc std microdil/agar dil,87186,HCPCS,306,RC,both,,,66.07,66.07,WELLPOINT TEXAS INC.,NACO05,,66.07,,,8.48,8.48,8.48,1 through 10,8.48,8.48,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,15,15,WELLPOINT TEXAS INC.,NACO05,,15,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Normal saline solution infus,J7050,HCPCS,258,RC,both,,,50,50,WELLPOINT TEXAS INC.,NACO05,,50,,,,,,1 through 10,50,50,percent of total billed charges,
Hospital observation per hr,G0378,HCPCS,762,RC,outpatient,,,868,868,WELLPOINT TEXAS INC.,NACO05,,868,,,,,,1 through 10,868,868,percent of total billed charges,
Ondansetron hcl injection,J2405,HCPCS,636,RC,both,,,30,30,WELLPOINT TEXAS INC.,NACO05,,30,,,6.39,6.39,6.39,1 through 10,6.39,6.39,percent of total billed charges,
Assay of lactic acid,83605,HCPCS,301,RC,both,,,69.19,69.19,WELLPOINT TEXAS INC.,NACO05,,69.19,,,,,,1 through 10,69.19,69.19,percent of total billed charges,
Tx/pro/dx inj same drug adon,96376,HCPCS,760,RC,both,,,278.01,278.01,WELLPOINT TEXAS INC.,NACO05,,278.01,,,,,,1 through 10,278.01,278.01,percent of total billed charges,
Pharmacy - General,250,RC,,,both,,,15.8,15.8,WELLPOINT TEXAS INC.,NACO05,,15.8,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Inj enoxaparin sodium,J1650,HCPCS,636,RC,both,,,34.89,34.89,WELLPOINT TEXAS INC.,NACO05,,34.89,,,,,,1 through 10,34.89,34.89,percent of total billed charges,
Comprehen metabolic panel,80053,HCPCS,301,RC,both,,,186.84,186.84,WELLPOINT TEXAS INC.,NACO05,,186.84,,,10.35,10.35,19.85,1 through 10,8.42,158.81,percent of total billed charges,
Ceftriaxone sodium injection,J0696,HCPCS,636,RC,both,,,15,15,WELLPOINT TEXAS INC.,NACO05,,15,,,4.43,4.43,4.43,1 through 10,4.43,5.53,percent of total billed charges,
Medical/Surgical Supplies and Devices - General,270,RC,,,both,,,2,2,WELLPOINT TEXAS INC.,NACO05,,2,,,163.59,76.2,1465.39,1 through 10,3.69,18135.46,percent of total billed charges,
Hydration iv infusion init,96360,HCPCS,760,RC,both,,,731.01,731.01,WELLPOINT TEXAS INC.,NACO05,59,731.01,,,208.38,208.38,208.38,1 through 10,208.38,927.64,percent of total billed charges,
Urinalysis auto w/scope,81001,HCPCS,307,RC,both,,,33.16,33.16,WELLPOINT TEXAS INC.,NACO05,,33.16,,,4.34,3.23,13.42,1 through 10,3.11,17.12,percent of total billed charges,